Exam 1: uterine blood flow, maternal phys, foundations, epidural, c section Flashcards
(479 cards)
1
Q
uterine blood supply pic
A
2
Q
what are changes in the Lt and Rt uterine artery in pregnancy
A
increase in size and flow on the same side of placenta (so if placenta on L side, so L side increases)
3
Q
where do uterine arteries branch from
A
internal iliac arteries
4
Q
what branch of the uterine arteries suply the myometrium and radial arteries
A
arcuate arteries
5
Q
what arteries branch to enter the endometrium to form the convoluted spiral arteries
A
radial
6
Q
what space does oxygenated maternal blood enter
A
intervillous space
7
Q
what invades the spiral arteries in a hypoxic state resulting in loss of smooth muscle tone
A
trophoblasts
8
Q
where does the the exchange of O2, nutrients, and waste occur between fetus and mother
A
blood directed at chorionic plate bathes the villi
9
Q
where does blood return fromfetus to mother
A
returns to basal plate and drains into multiple collecting veins
10
Q
describe path of venous drainage of uterus
A
uterine veins-> internal iliac and utero-ovarian plexus-> inferior vena cava on right and renal vein on left
11
Q
what does blood sample from intervillous space resemble
A
mixed venous
12
Q
maternal fetal blood exchange picture
A
13
Q
placental blood supply picture
A
14
Q
what is uterine blood flow at term
A
700-900ml/min
15
Q
uteroplacental blood makes up _________- perecent of maternal cardiac OP
A
12%
16
Q
what is umbilical blood flow
A
110-120ml/min/kg
17
Q
what are the three stages of changes in uterine blood flow
A
1- before and during implantation and early placentation
2- Growth and remodelingof uteroplacental vasculature
3-progressive uterine artery vasodilation
18
Q
as flow to common iliac and uterine arteries increases blood flow to what artery decreases
A
external iliac
19
Q
how does increased SVR effect placental blood flow??
A
decreased
20
Q
how is SVR in uteroplacental circulation
A
low
21
Q
uteroplacental circulation is _______ dependent
A
pressure
22
Q
T/F uteroplacental circulation has well controlled autoregulation
A
false
23
Q
if maternal BP is decreased, what happens to placental blood flow
A
decreased
24
Q
uterine blood flow = __/_____
A
uterine perfusion pressure/uterine vascular resistance
25
what are some things that decrease uterine perfusion pressure FROM decreased uterine arterial pressure
supine position (aortocaval compression)
hemorrhage/hypovolemia
drug-induced hypotension
hypotension during sympathetic blockade
26
what are some things that decrease uterine perfusion pressure from increased uterine venous pressure
venal caval compression
uterine contractions
drug-induced uterine tachysystole (oxytocin, LAs)
skeletal muscle mypertonus (sezures, valsava, peep)
27
what are uterine effects of high doses of oxytocin
uterine tachysystole and decreased uterine blood flow
28
what are some causes of increased uterine vascular resistance FROM endogenous vasoconstrictors
catecholamines (stress)
vasopressin (in response to hypovolemia)
29
what are some causes of increased uterine vascular resistance FROM exogenous vasoconstrictors
epinephrine
vasopressors (phenylephrine>ephedrine)
LAs
30
does neuraxial anesthesia increase or decrease uteroplacental blood flow?
epidural CAN increase blood flow UNLESS you drop mother HR, BP, or put in supine position
31
which vasopressor is better at treating maternal hypotension
ephedrine (produces more uterine blood flow, but lower umbilical pH)
but Crouss says phenylephrine is safer
32
T/F commonly use induction drugs decrease uterine blood flow
false
33
T/F volatiles anesthetics decrease uterine blood flow
false
34
T/F hypoxia and hypercarbia decrease uterine blood flow
true
35
what are we minduful on during induction related to uterine blood flow
hypotension can decrease uterine blood flow
laryngoscopy can decrease uterine blood flow 2/2 NSS response
36
what effect does SNS response have on uterine blood flow
decreases
37
what can we do to furhter dilate placental artieries
nothing, they are already maximally dilated from trophoblasts
38
what is the effect of 5L of O2 on uterine blood flow
can causes vasoconstrictive affects-> decrease UBF
39
what is the average amount of weight gain in pregnancy
17% or 12 kg
40
what is the breakdown of weight gain in pregnancy
amniotic fluid 1 kg
fat 4kg
uterus 1 kg
fetus placenta 4kg
blood volume 1 kg
interstitial fluid 1kg
41
T/F in pregnancy your heart increases in size
true
42
what heart tone is often heard in pregnancy
4th tone
43
what causes the grade 2 systolic murmur at L sternal border
tricuspid and pulmonic regurge (benign)
44
when do pregnant patients develop LVH
12 weeks
45
how is HR affected by pregnancy
increases
46
what causes the increase in CO in the first trimester of pregnancy
HR
47
what causes the increase in CO in the 2nd trimester
SV
48
what hormone correlates with the increase in SV
estrogen
49
when does the increase in CO begin
5 weeks
50
what causes the decrease in SVR in pregnancy
low resistance in pregnancy
51
how is EF in pregnancy
increased
52
how is LVESV in pregnancy
same
53
how is LVEDV in pregnancy
increased
54
where is perfusion increased in pregnancy
uterus
skin
kidneys
extremities
55
what does increased skin perfusion lead to
flushing, heat loss
56
uterine blood flow increases from 50 ml/m to __________ ml/m by term
700-900
57
what percent of cardiac output goes to uterus in second half of pregnancy
12% (5% pre pregnancy)
58
what position do you put pregnant patient in to prevent aortocaval compression
left lateral about 30*
59
when can aortocaval compression begin
13 weeks
60
what does supine position affect pregnancy patient
10-20% decline in SV and CO, decreased RA filling pressure
61
how dose supine position affect uterine blood flow
decrease by 20%
62
how does supine position affect lower extremity blood flow
50%
63
what are s/s supine hypotension syndrome
light headedness
n/v
chest heaviness
64
how does sitting up effect BP
can be 10% decrease do to low SVR state
65
how can we combat decrease in BP when placing spinal/epidural
lateral position OR bend legs up
66
what happens to CO right after delivery
up to 150% increase above prepregnant baseline
67
how much does CO increase in early first stage labor
10%
68
how much does CO increase in late first stage labor
25%
69
how much does CO increase in second stage labor
40%
70
how much does CO increase immediate postpartum
75%
71
how is CO 24 hours post partum
24 hours postpartum decreases to just below prelabor levels
72
when dose CO return to baseline
12-24 weeks
73
what causes the rapid increase in CO after delivery
no AV compression
decreased low resistance placenta
74
how does uterine contraction effect blood
displaces 300-500 ml
75
when does HR return to baseline
2 weeks
76
what hormone relaxes ligament and cartilage in pregnancy
relaxin
77
what happens to the subcostal angle in pregnancy
widens (69-104*)
78
what happens to the vertical measurement of chest cavity
decreases (4cm)
79
what happens to the AP and traverse diameters in pregnancy
increase (2 cm by 37 2weeks)
80
what happens to capillaries of larynx and nasal/oropharyngeal mucosa
capillary engorgement
81
T/F use nasal trumpets/nasal intubation in preggers
false
82
what happens to airway in preggers
friable, bleeds
83
how is nasal breathing
difficult
84
how is pulmonary resistance in pregnancy
decrease 50%
85
how is chest wall excursion in pregnancy
decreased
86
how is diaphragm excursion in pregnancy
increased
87
how is FEV1 in pregnancy
unchanged
88
resp changes
89
how is flow volume loop in resp
no change
90
how is Total lung capacity in pregnancy
slightly reduced
91
how is TV in pregnancy
increased by 45%
92
how is expiratory reserve in pregnancy
decreased by 25%
93
how is residual volume in pregnancy
decreased by 15%
94
how is MV in pregnancy
45% increased
95
how is VC in pregnancy
maintained
96
how is RR in pregnancy
increased slightly
97
what are the pulmonary volumes that are decreased in pregnancy
expiratory
residual
(TLC slightly)
98
how is closing capacity in preggers
no change
99
T/F dyspnea affects up to 75% of women during pregnancy
true
100
what ph state are pregnancy in
resp alkalosis
101
how is PaO2 in pregnancy
increased
102
how is PaCO2 in pregnancy
decreased
103
how is pH in pregnancy
increased
104
how is bicarb in pregnancy
decreased
105
what causes the increase in PaO2 in pregnancy
increased alveolar ventilation
106
how is stomach affected by pregnancy
stomach displaced up and to the left, axis is rotated 45*
decreased lower esophageal sphincter tone
107
at how many weeks does a pregnant patient become aspiration risk
any week, RSI
108
GI changes chart
109
when do preggers have delayed gastric emptying
labor
110
T/F pregnant patients have increased gastric acid secretion
false
111
what is an important drug to give preop for preggers
antiemetic/zofran (80% have N/V)
fix the N/V before
112
what is a potential issue with zofran
leads to birth defects
113
how is liver affected by preggers
liver displaced upward
increased bilirubin,alanine aminitransferease, aspartate aminiotransferease, and lactate dhydrogenase
114
how does preggers effect gallbladder
gastric smooth muscle relaxes leading to billiary stasis and increased gallstones
increased rates of lap Chole
115
how long after birth do women still have aspiration risk
7 days
116
how is renal blood flow affeted by pregnancy
increases by 75%
117
how is GFR affected by preggers
increased by 50%
118
how is creatinine clearance in preggers
150-200 ml/min
119
T/F protenuria is only possible with preeclampsia
false
120
how is urine glucose in preggers
increased
121
T/F twin pregnancy has higher proteinuria
true
122
T/F later term has higher proteinuria
true
123
what causes the physiologic anemia in preggers
increased plasma volume
not as much increased RBC
124
when do RBCs decrease in preggers
8 weeks
125
when do RBCs return to baseline in preggers
16 weeks
126
how does blood volume change in pregnancy
increased 45%
127
how does plasma volume change in pregnancy
increased 55%
128
how does RBC volume change in pregnancy
increased 30%
129
what is a typical hgb concentration g/dL
chart says 11.6
crouss said aroun 9
130
typical hct in pregnancy
chart says 35.5%
131
how is cholinesterase affected in preggers
25% decrease (drops during first trimester)
132
how much blood is lost in normal vaginal delivery
600ccs
133
when is the greatest decrease in psuedocholinesterase activity
3rd day postpartum
134
when do you use succs during preggers
emergency c section
no need to redose paralytics
135
T/F the psuedocholinesterase deficiency affects succs metabolism
false
136
what factors are increased in preggers
1,7,9,10,12
137
what factors are unchanged in preggers
2,5
138
what factors are decreased in preggers
11, 13
139
what bleeding/clotting state is preggers
hypercoag
140
how are platelets in preggers
greater production and consumption
8% have platelet count <150,000
141
what is normal blood loss in c section
1000ccs
142
what makes c section blood hard to estimate
amniotic fluid
irrigation
143
how are clotting factors post partum
rapid decrease in
platelets,
fibrinogen,
factor 8 and
plasminogen
144
when does coags return to normal postpartum
2 weeks postpartum
145
how is immune system in preggers
immunocompromised
146
how are leukocytes in preggers
increased to 9-11,000 up to 15000
147
how are autoimmune disorders in preggers
improved
148
what kind of T cells are in successful preggers
th2
149
what kind of T cells are in miscarriage
Th1
150
how is thyroid in preggers
enlarges 50-70%
151
which Thyroid hormones are increased
estrogen increased T3 T4
152
how is TSH in preggers
same
153
how many preggers have gestational hypothyroid
15%
154
how is insulin affected
insulin resistance
155
how are cortisol levels
2.5x higher at end of 3rd trimester
156
how is calcium in preggers
insufficient 2/2 fetal demand
157
T/F post partum back pain is from epidural
false, relaxin
158
how does preggers effect sleep
disturbed REM cycle
159
how is cerebral blood flow in preggers
increased 2/2 decreased cerebral vascular resistance
160
how is BBB
more permeable
161
how is epidural space in preggers
epidural fat and venous plexus enlarge
162
how is CSF volume in preggers
decreased
163
how is CSF pressure in preggers
same
164
during preggers dependence on the SNS is (increased/decreased)
decreased
165
why is it important to stay midline in epidural
enlarged venous plexus
166
what is best position to avoid AV compression in preggers
L lateral 15%
167
how do we position after spinal
raise head up (10*)
168
what do we watch for high spinal
pinky numb/tingle C8
169
how many class 4 mallampati
increased by 34%
170
what makes preggers higher to iNtubate
DECREASED FRC
swollen tissue
tissue demands of fetus
class 4 airways
171
in preggers PaO2 decreases _______ x faster
2
172
how long do you have till hypoxia in preggers
2-3 min
173
what kind of airway equip should you have in preggers
videoscope
174
how is MAC in preggers
40% lower
does not affect anesthesia requirements in practice
175
T/F use lots of narcs in preggers
false
risk of fetal bradycardia
176
how are Beta adrenergic receptors in preggers
down regulated
so need higher doses of vasoactives if using
177
what makes neuraxial anesthetics more difficult in preggers
lordosis
increased weight
increased bleeding
178
what is a complication for neuraxial
hypotension
difficulty breathing
179
what are risks for ectopic preggers
previous ectopic
intertility tx
prior pelvic infection
tubal sx
advanced maternal age
180
where do most ectopic implantation occur
tubal
181
what are s/s ectopic
pelvic pain
delayed menses
vaginal bleeding
abd pain with or without tenderness
signs of shock
182
what is the leading cause of maternal death in the US
ruptured ectopic
183
what is ectopic called before it is diagnosed officially
pregnancy of unknown location
184
what is the gold standard of diagnosising ectopic
transvaginal ultrasound
185
how does ectopic appear on ultrasound
adnexal mass with free fluid
186
how do seerial HCGs diagnose ectopic
serial for 48rs, if it does not increase by 53% then possible PUL
187
what does a decrease in HCG by 10% tell us
failed pregnancy
188
what labs do you do for PUL
HCG
progesterone
pregnancy test
189
what is your induction med for ectopic
etomidate
190
how do you prepare for ectopic case
2 ivs
fluid
blood
etomidate induction
type and scree/cross
aspiration prophylaxis
urinary catheter
RSI
vasopressors ready
a-line if unstable
Ng tube
warming device
pitocin
191
when does aspiration risk begin in preggers
1st week
192
what is EPL
early pregnancy loss, term for spontaneous incomplete abortions
193
when do EPLs occur
8-14 weeks
194
what is surgical procedure for EPL
D&C or D&E
195
what is D&E for
larger fetus
196
what is complication of retained fetus
sepsis
197
what is anesthetic technique for EPLs
type and cross/screen
aspiration prophylaxis
urinary catheter
large bor IV
RSI
etomidate
monitors
vasopressors
a line if unstable
NG tube
warming device
198
what do we give after D&C
methergine, hemobate, pitocin
199
when do we stop pitocin for DC
before instrumentation
200
when do we restart pitocin
after removal of fetus
201
what can long term use of pitocin use
uterine atony after dc, give smaller dose after long term use
202
what is the inability of a cervix to hold a pregnancy
cervical insufficiency/incompetency
203
what procedure is performed for cervical insufficiency
cerclage procedure
204
what is preferred if cervix is not dilated and membranes are bulging
spinal anesthesia (sacral to T10)
205
what is goal of cerviccal insufficiency tx
prevent rupture of membranes
206
what is the most common medical disorder in preggers
HTN
207
what is risk of HTN
fetal complications
207
what is the most common cause of HTN in pregnancy
gestational HTN
208
how often does HTN occur
10% of preggers
209
what is true gestational HTN
HTN that is new onset and returns to normal after birth
210
what is the only cure for preeclampsia
delivery of fetus/placenta
211
how is PREclampsia defined
new onset HTN and proteinuria AFTER 20 weeks gestation
212
what is the leading cause of indicated preterm delivery
peeclampsia
213
what are the two kinds of preeclampsia
with or without severe features
214
sever features vs without sever features preeclampsia
215
what kind of preeclampsia is for blood pressure greater than or equal to 140/90
without severe features
216
what kind of preeclampsia has BP > 160/110, thrombocytopenia, pulmonary edema, visual disturbances, impaired liver function
severe preeclampsia (with complications)
217
what are complications of Preeclampsia
narrowing of airway
40% reduction in plasma volume
pulmonary edema
thrombocytopenia
DIC
HELLP
placental abruption
fluid volume overload
increased LVEDP
Pump Htn
Swollen legs
218
what is HELLP syndrome
hemolysis, elevated liver enzymes, low platelets
219
what is goal week for preeclampsia delivery
after 37 weeks
220
when is delivery for sever preeclampsia
<34 weeks
221
what do you do to treat delivery for preeclampsia <34 weeks
delay for 24-48 hours for corticosteroid treatment
administer anti htn and mag
222
what are preffered anesthesia methods for preeclampsia
CLE and CSE or spinal over GA
223
how often do you monitor platelets for preeclampsia
every 24 hours, can get below 100,000
224
how is CO affected by birth
it increases, so with preeclampsia pulmonary edema can occur and sharp spike in BP
225
preeclampsia tests
226
HELLP chart
227
hypertensice disorders of pregnancy
228
what is eclampsia
new onset of seizures/coma with symptoms of preeclampsia
229
when can eclampsia occur
4 weeks postpartum
230
what happens to fetus after seizures for eclampsia
fetal bradycardia
231
what do we give for eclamptic seizures
magnesium (4-6 grams over 20 min)
232
what are goals of spinal/epidural anesthesia for labor
pain relief
safety for mother and fetus
continued progression of labor
retain ability to push
minimize SE
have a long duration
be flexible
minimize time demands for anesthesia provider
233
T/F epidurals delay labor
false
234
what does pain in the first stage of labor come from
distention of lower uterus and cervix
-visceral pain
T10,11,12
235
what does pain in the second sage of labor come from
somatic
pudendal S2,3,4
236
what are benefits of analgesia in labor
-better uteroplacental perfusion and uterine activity
- decreased hyperventilation
-decreased paternal anxiety/fear
-decreased catecholamines = increased blood flow to fetus
237
T/F epidurals are elective
true
238
Can someone who got a tattoo right on epidural spot 4 months ago have epidural
no
239
Can someone who got a tattoo right on epidural spot 6 months ago have epidural
yes
240
Can someone who got a tattoo with metalic ink right on epidural spot 4 months ago have epidural
no
241
contraindications to epidural
242
what are some other contraindications to neuraxial
mechanical valves
blood thinners
243
T/F you have have neuraxial anesthesia with porcine valve
false
244
what are indications for Spinal/epidural
Maternal/OB request
Breech deliveries
Twins
245
what are some benefits for spinal epidural
facilitates BP control in preeclampsia
blunts hemodynamic fluctuations during contraction
246
what is gynecological recommendation for epidural
4-5 cm dilation
247
what do you do to prepare for spinal/epidural
review OB history
preanesthetic eval
physical exam
review labs
inform and answer question
signed consent
248
T/F you can have spinal/epidural with Skin infection
T, as long as infection is not right on insertion site
249
T/F you can have spinal/epidural with systemic infection
F, look for increased WBCs
250
T/F you can have spinal/epidural with platelets <100,000
F, >100,000 is okay
251
T/F you can have spinal/epidural with anticoagulants
F
off ASA for 7 days
off heparin for 24 hours
252
what equipment do we need for spinal/epidural
Airway cart
epidural cart
lipids
resuscitation meds
working IV
253
what monitors do we need for spinal/epidural
BP, EKG, pulse ox, ambu, suction, FHR monitor
254
how do we pretreat for spinal/epidural
1000ccs crystalloid
colloid
255
how do you position for epidural/spinal
side of bed, straight back
256
how often do you check vitals after test dose/ initial bolus
Q5 min for 15 minutes
257
what is the benefit to lateral position over sitting for spinal placement
lower csf pressure
258
what are layers for epidural /spinal placement in medial approach
skin
subq
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura
interthecal spinal space
259
what are the benefits of continuous epidural
contnuous and variable levels of anesthesia
ability to extend to C section
no dural puncture
caudad and cephalad spread
controlled by pump with bolus feature
260
what are negatives of continuous epidural
slower onset
large volumes of LA required
higher failure rate
261
what two layers do you skip in paramedian approach
supraspinous and interspinous ligaments
262
which approach has more vessels, medial or paramedian
paramedian
263
what are benefits of CSE
confirms epidural space
same benefits as epidural
more rapid onset
much faster sacral analgesia
less chance of failure
264
T/F CSEs have an increased chance of postdural puncture HA
false
265
what are negatives of CSE
can cause pruritis
possible inadvertant intrathecal catheter insertion
dont know if epidural is working
hypotension
spinal will wear off
high spinal
266
when bolusing epidural what is the rule for volume/dermatome
1 level = 1 ml
267
what is normal CC injection
6-8 ccs
268
epidural vs CSE
269
what are benefits of DPE
same benefits as epidural
faster onset for sacral spread and overall more dense block
less failed blocks
less unilateral blocks
faster onset
270
which has faster onset CSE or DPE
CSE
271
what is negative of DPE
possible intrathecal cath placement
272
how do you make sure your catheter is not in spinal space
test dose
273
what is benefit of continuous spinal
extends block beyond typical intrathecal injection
can be used in event of accidental dural puncture
274
what are negatives of continuous spinal
high risk for post-dural puncture HA
risk for high spinal
275
when do we use continuous caudal caths
typically only used for chronic pain
can be used for prior surgery where epidurals are not an option
276
what are benefits of single shot spinals
provides almost immediate analgesia
dense block
low LA dosage
277
what are negatives of single shot spinal
limited effective analgesia time
can block motor function
278
what do we do to identify unintentional cannulation of the subarachnoid space or blood vessel
epidural test dose
279
what meds do we give for test dose
3ml of
1.5 lido (45 mg)
1:200,000 epi (15mcg)
280
T/F we give test dose during a contraction
F, time it between contractions
281
what is a positive epidural test dose
risk in HR or BP 20% above baseline
symptoms of lidocaine toxicity (ringing in ears, metalic taste, numb feet)
282
what do you do if you have a postive test dose
pull back catheter
redo test dose
replace epidural
283
which shoulder do you put epidural line on
same side as IV
284
how far do you put epidural catheter in space
text book like 3-5 cm, palmer says 7-10 cm
285
which epidural drug treats visceral pain
opioids
286
which epidural drug treats somatic pain
LAs
287
where are dense concentrations of opioid receptors located
dorsal horn of spinal cord
288
what epidrual drug would you give for lower uterine segment and cervicle dilation pain
opioids (visceral)
289
what epidural drug would you give for descent of fetus into birth canal pain
LA (somatic)
290
what is concentration of epidural bupivicaine
0.125%
291
T/F bupivicaine blocks motor
false
292
bupivicaine facts
highly protein bound
pain relief in 8-10 minutes
peaks in 20 min
duration 90 minute single dose
cardiotoxic
doesnt block motor
293
what is concentration of ropicivaine for rescure
0.25-0.5% 8-10 ccs rescue
294
what is relationship of ropivicaine and bupivicaine
ropivicaine is the single levorotary enantiomer of bupivicaine?
295
ropivicaine facts
less potent than bupivicaine
less motor blockade than bupivicaine
less cardiotoxic than bupivicaine
296
when do we use lidocaine for epidural
c section
297
lidocaine facts
shorter DOA
less protein bound
increased motor blockade
very dense block
298
when do we use 2-chloroprocaine
emergency c section, good drug to top off crowning or retained placenta
299
2-chloroprocaine facts
ester LA
rapid onset
short DOA
300
what are characteristics of lipid soluble opioids for epidural
rapid onset
short DOA
greater systemic absorption
reduce amount of LA needed
301
what is best combo of epidural opioids
a lipid-soluble and a water soluble
302
what are examples of water soluble opioids
morphine, hydromorphone, meperidine
303
which opioid has some LA properties
merperidine
304
what are properties of water soluble opioids
long latency
long DOA
inconsistent analgesia
more sedation
305
what is benefit of epinephrine as an adjuvant
1.25-5 mcg
shortens latency, prolongs doa, reduces LA dose by 29%
306
how does clonidine work as an adjuvant
direct stimulation of Alpha 2 adrenergic
307
what is action of acetylcholine as adjuvant
inhibits breakdown of acetylcholine which increased GABA
308
what is benefit of LA and opioid
lower total dose of anesthetic
decreased motor blockade
reduced shivering
greater patient satisfaction
309
what two locals are usually in epidural pump
ropivicaine
bupivicaine
310
how can you test if epidural is working
have raise legs, if they can its no good
311
what do you do with bad epidural
replace it
312
managing bad epidural chart
313
what do you do if you accidentally puncture dura
remove needle and try another level
transition to CSE
place catheter intrathecal
314
what increases risk of ectopic pregnancy
previous ectopic
infertility treatment
prior pelvic infection
tubal sx
advanced maternal age
315
esters vs amines
316
which LA does not contain a desaturated carbon ring and a tertiary amine
cocaine
317
T/F pregnancy requires higher doses of LA
false
smaller
318
how does pregnancy affect LAs
engorgement of epidural veins
increased neuronal sensitivity
progesterone or its metabolite
higher pH
319
what are s/s LAST
tongue numbness
lightheaded
muscle twitching
unconsciousness
convulsions
coma
resp arrest
cardiovascular collapse
320
how do we treat LAST in preggers
call for help
position for L uterine displacement
20% lipids
100% O2
maintain airway
control seizures
support BP with pressors fluid
consider bypass
321
T/F LA allergies are common
false
rare
322
T/F LAs easily cross placenta
T
protein biding
lipid soluble
ionizing
323
neonatea are (more/less) sensitive to CNS depressant effects of LAs
less
324
what are Fetal heart rate changes usually related to
LA effect on mother such as hypotension
325
opioid receptor types
326
what kind of receptors do opioids bind to
G protein coupled opioid receptors which inhibit adenylate cyclase and voltage gated calcium channels
327
what is the result of opioids inhibiting clacium channels
release of glutamate and supstance P
-ionhibition of ascending nociceptive stimuli form dorsal horn of spinal cord
328
what is the site of action of epidural opioids
dorsal horn of spinal cord
329
what can happen to fetus if opioids get transmitted
resp depression
decreased APGAR
bradycardia
330
how do opioids cause fetal bradycardia
linked to decreased maternal epinephrine
leads to uterine hyperactivity
331
what is the most common major surgicial procedure performed worldwide
c section
332
what is the most common indication for C section
labor arrest (34%)
333
T/F prior c section means you will always have C section
F (VBAC)
334
what are indications for C section
fetal heart tones (23)
breech presentation (17)
multiple fetus (7)
335
when do they do vertical c section incision
preterm, more emergent, lower presentation
336
what is uterine exteriorization
take uterus
337
what type of incision for nonemergent c section
horizontal
338
what happens when putting uterus back in
nausea- pretreat with zofran
339
T/F c section have a higher death rate than vaginal
F, just as safe as vaginal
340
T/F neuraxial anesthesia results in higher C section rates
false
341
T/F epidurals slow down labor
false
342
how do you position after epidural
wedge hip alternate
343
what are methods to do intrauterine resuscitation
positioning (L lateral)
O2
maintain BP
stop pitocin
treatment of uterine tachysystole
344
what medications do we give to maintain BP in intrauterine resuscitation
Phenyl, ephedrine
345
T/F only get consent for mothers who say they want a C section
F, everyone is possible
346
what can we do for high risk patients before they are admitted for birth to ensure safe anesthetic delivery
pre anesthesia consult
347
what is the leading cause of maternal mortality
peripartum hmmg
348
what anesthesia medications do we avoid in c section
narcs
non-depolarizers
volatiles
349
what can non-depolarizers lead to
paralyze the uterus=uterine atony= bleeding
350
what can volatiles cause in c section
uterine atony
351
what paralytic do we use for c section under general
succs
352
what can we give mother after baby is taken out in C section
turn up N2O
give narcs
turn down sevo
353
what is the limit for clear liquids for c section
nonlaboring healthy patients can have clear liquids up to 2 hours
354
how can we prophylactically treat for aspiration in c-section
antacid
H2 antagonist (pepcid_
PPIs
promotility (reglan)
355
what is a consideration for treating aspiration with meds
use multiple agents
30 minute onset
356
how much ancef do we give for <100 kg
2 gm
357
how much ancef do we give for >120kg
3gm
358
how do we dose ABX
weight
359
when do we give ABX
within 60 minutes of incision
360
what fluids do we give before spinal
1L cystalloid BUT
albumin is better (500)
361
how many IVs for csection
2 large bore
362
what neuraxial do we do for scheduled C section
spinal
363
what neuraxial do we do for emergent c section
general
364
what neuraxial do we do for failure to progress c section
epidural
365
what is positioning for c section
at least 15 degree L lateral
head up 10 degrees after spinal
366
what position do we put c section patient in for neuraxial
lateral or sitting
367
when do we give mother O2
fetal distress
368
what kind of oxygen do we give for scheduled C section
NC
369
what kind of oxygen do we give for emergent C section that may turn to general
100%
370
what is a good pretreat medication for C section
anxiety
371
emergent vs urgent vs scheduled c section
372
what kind of C section is for prolonged fetal bradycardia
emergency
373
what kind of C section is for deep variable dcels with cervical dilation of 3 cm
urgent
374
what kind of C section is for ruptured memebranes with previously undiagnosed breech presentation
scheduled
375
what kind of C section is for repeat C section
elective
376
what type of C section is for immediate threat of life to mother or fetus
emergent
377
what type of C section is for maternal or fetal compromise that is not immediately life threatening
urgent
378
what type of C section is for needing early delivery but no maternal or fetal comprimise
scheduled
379
what type of C section is at a time that suits the mother and delivery team
elective
380
what is goal level of epidural redose for C section
T4
381
what medication can we give in epidural to speed up onset
bicarb
382
what is the type of anesthetic for c section determined by
urgency of c section
383
once a mother is under GA, how long does the surgeon have to get the baby out
8 minutes
384
when should surgeon cut under Genderal C section
as soon as eyes are closed/meds pushed
385
what do you always do after C section? why
Xray, see if anything left
386
how often is nueraxial used in emergent C section
80%, sometimes not enough time
387
what is goal sensory level for c section
T4
388
what are advantages of spinal for C sec
visualization of CSF
technically easier
more rapid
more dense
less risk of LA
predictable recovery
389
what is the duration of spinal
2-3 hrs
390
what is the max dose of spinal
2 ccs total
391
Why do we give dextrose in spinal
baricity (dextrose is hyperbaric)
392
what is the drug of choice for spinals
bupivicaine 0.75% in 8.25% dextrose
393
what is the most common dose of spinal
10-15 mg
394
spinal med doses
395
what kind of morphine do you use for spinals
duramorph-preservative free
396
how is resp depression with duramorph
delayed reaction
397
what are benifits of intrathecal opioids
-reduce intraoperative supplemental analgesia by 20%
-reduces N/V
398
what are lipid soluble (fast) opioids
fent
alfent
sufent
remifent
399
what are the water soluble (slow opioids)
morphine
400
T/F higher doses of intrathecal opioids increase analgesia
F, increase pruritus
401
what can we give to treat pruritis from intrathecal opioids
narcan in NS slow dripped
402
what are some spinal analgesia adjuvents
dextrose
epi
clonidine
dexmetomidine
403
how much bicarb do we give for spinal
1/10th total volume
404
T/F clonidine and precedex have less side effects than opioids
true
405
what is potential side effects of clonidine/precedex
vasodilation
406
what is the best range for fentanyl dosing
10-15mcg
407
T/F epidural anesthesia is more reliable than spinal anesthesia
false
408
how are epidural doses compared to spinal doses
5-10x higher
409
what are adjuvents for epidurals
fentanyl
sufenta
morphine
hydromorphone
clonidine
epi
sodium bicarb
dexmetomidine
410
epidural anesthesia doses
411
what medication do we give with epidural to prolong block
epi
412
what is the goal block for epidural
T10-T4
413
how is intubation for GA for C section
difficult
reduce ETT size
short laryngoscope handle
video laryngoscope
414
what operative prep must be done BEFORE initiatiating GA in c section
prepped and draped
415
T/F delay C section incision until ETT confirmation
T, but palmer says F in practice
416
what is the benefit of GA in C section
less aspiration
417
what are goals for anesthesia and C section
adequate maternal and fetal O2
adequate depth of anesthesia
minimize effects on uterine tone
minimize effects on the neonate
418
when can we give mother IV opiods
after delivery
419
what kind of Muscle relaxers are avoided in C section
non-depolarizing
420
how do volatiles affect c section
decrease uterine tone and BP
decreased uterine blood flow
421
what are recovery issues from C section
pain
sedation
N/V
pruritis
prolonged neuroblockade
drug treatment
bleeding
422
T/F a one time dose of toradol causes bleeding
false
423
what can cause lower neonatal apgar scores
depth of maternal anesthesia
delivery time > 8 minutes
424
T/F we want lack of recall with C section
false
425
T/F at T4 blockade you can still feel yourself breathing
false
426
how do we respond to high spinal
RSI
427
what is a common side effect of neuarxial block and what causes it
hypotension, sympathetic nerve fibers blocked
428
how can we prevent hypotension from spinal
IV fluid bolus 1 L (or 15 ml/kg)
colloid is better
ephedrine vs phenylephrine
lower doses of LAs
429
how do we prevent N/V
pretreat with zofran
430
what other complication can hypotension lead to in neuraxial
n/v
431
what are causes of N/V in C section
exteriorization of uterus
intra-abd manipulation
hypotension
432
risk factors for NV chart
433
what is optimal dose of intrathecal morphine
0.1mg
434
what is optimal dose of epidural morphine
3.75mg
435
what is another block to treat pain in c section
tap block
436
what is the most effective treatment for pruritis in neuraxial
narcan
437
what is the best drug to treat shivering
merperidine
438
why does neuraxial cause hypothermia
vasodilation
439
T/F uterine atony is more common after C section
true
440
T/F push oxytocin
false
drip it in (40 units in a liter wide open)
441
what can rapid bolus of oxytocin lead to
hypotension and cardiovascular collapse
442
what route do we give methergine and hemabate
IM
443
Pka 2-chloroprocaine
8.9
444
Pka tetracaine
8.6
445
Pka lidocaine
7.9
446
Pka bupivacaine
8.2
447
Pka ropivacaine
8.0
448
Fentanyl spinal
10-25 mcg
449
Sufenta spinal dose
2.5-5 mcg
450
Morphine spinal dose
100-200mcg
(0.1-0.2mg)
451
Dilaudid dose spinal
60-75 mcg
(0.060-0.075mg)
452
Demerol spinal dose
60-70mg
453
Epi spinal dose
100-200mcg
(0.1-0.2mg)
Just do epi wash
454
Fentanyl epidural dose
50-100mcg
455
Sufenta epidural dose
10-20mcg
456
Morphine epidural dose
3-4 mg
457
Dilaudid epidural dose
0.6-1.5 mg
458
Merperidine epidural dose
50-75mg
459
Normal TV
500
460
Normal ERV
1100
461
Normal residual volume
1200
462
Normal IRV
3000
463
Normal FRC
2300
464
Normal inspiratory capacity
3500
465
Normal vital capacity
4500
466
Normal Total Lung Capacity
6000
467
Factor 1
Fibrinogen
468
Factor 2
Prothombin
469
Factor 3
Thromboplastin
470
Factor 4
Calcium
471
Factor 5
Labile factor
472
Factor 7
Stable factor
473
Factor 8
Antihemophilic factor
474
Factor 9
Christmas factor
475
Factor 10
Stuart prower factor
476
Factor 11
Plasma thromboplastin antecedent
477
Factor 12
Hageman factor
478
Factor 13
Fibrin stabilizing factor
