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Anesthesia OB > General OB Anesthesia > Flashcards

General OB Anesthesia Flashcards

1
Q

Respiratory effects of pregnancy and anesthetic

A
  • Swelling of nasal and oral
  • Increases in MV, TV, VO2, Not RR (returns 6 wks PP)
  • PaCO2 to 30 by week 12, pH to 7.44 with metabolic compensation
  • Decrease in FRC (returns by 2 weeks PP)
  • Use smaller ETT, possible difficult intubation
  • Preoxygenate 3-5 min or 4 VC breaths (reduced FRC and increased VO2)
  • MAC decreased 40%
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2
Q

CV effects of pregnancy

A
  • Increased CO (highest immediately PP)
  • Increased SV, HR
  • Decreased SVR, DBP
  • No change in BP
  • Aortocaval compression (left uterine displacement)
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3
Q

GI effects of pregnancy

A
  • Decreased motility during labor
  • Decreased LES tone
  • Increased aspiration risk
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4
Q

Hematologic effects of pregnancy

A
  • Increased fluid volume, plasma volume, RBC volume
  • Anemia of pregnancy (11 g/dL)
  • Increased coagulation factors with shortened PT and PTT
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5
Q

Labs for healthy cesarean

A
  • CBC with platelets

- Type and cross with 4 units (if increased risk of bleeding)

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6
Q

Preoperative medications for healthy cesarean

A
  • Nonparticulate antacid Sodium citrate 30 minutes prior to anesthesia (goal pH > 2.5)
  • IV H2 antagonist (ranitidine)
  • Fasting guidelines as per non-OB
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7
Q

Monitors, lines for healthy cesarean

A

Std ASA monitors

  • EKG, BP, pulse ox, ETCO2, Foley
  • Two large bore IV catheters
  • Forced air warmer
  • IV fluid warmer
  • Intermittent pneumatic compression stockings
  • Consider a-line
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8
Q

Anesthesia choice for Placenta previa, accreta, increta, percreta

A
  • Regional is ok for previa, accreta and increta
    • Single shot is probably not good idea
    • May need to convert to GA if massive bleeding
  • General for percreta
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9
Q

Absolute and Relative contraindications to neuraxial anesthesia

A

Absolute

  • Pt refusal
  • Hypovolemia
  • Infection at needle site
  • Coagulopathies
  • Mass lesions causing increased ICP

Relative

  • Systemic infection (OK if treated)
  • Neurological disease (rare)
  • Isolated coagulation abnormalities
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10
Q

Expected blood loss

A

Vaginal 500 ml
Cesarean 1000 ml
Cesarean Hysterectomy 1500 ml

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11
Q

Physical findings of blood loss

A

< 20%
None

20-30%
Tachycardia, tachypnea
Narrowed PP
Orthostatic hypotension

30-40%
Worsening tachycardia and tachypnea
Hypotension
Oliguria

> 40%
Shock
Altered consciousness
Anuria

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12
Q

Postpartum hemorrhage causes

A
  • Early <24 hrs, and late up to 6 weeks
  • Bleeding from placental implantation site
    Myometrial hypotonia (uterine atony)
    Placenta previa
    Retained placental tissue (accreta)
  • Bleeding from genital tract trauma
    Lacerations
    Uterine rupture
  • Coagulation deficits worsen bleeding
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13
Q

Physiology of placental separation

A
  • At term 600 mL per minute flows in placenta
  • With placental separation, spiral vessels are avulsed
  • Myometrium contracts and compresses large vessels
  • Next clotting occurs
  • Often it is the lower uterine segment that has less myometrium which contracts poorly
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14
Q

Drugs and maneuvers to enhance myometrial coagulation

A
  • Manual uterine massage
  • Uterotonic medications
    Oxytocin (Pitocin is synthetic oxytocin)
    Increase frequency and duration of contactions
    20 units in 1L crystalloid
    Can cause hypotension via decreased SVR
    Ergot alkaloids
    Methylergonovine (Methergine) IM
    Tetanic contractions
    Avoid in hypertensive
    Risk of coronary artery spasm
    Prostoglandins
    15-methyl prostaglandin F2 (Hemabate, Carboprost)
    Avoid in asthma (bronchoconstriction)
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15
Q

When to transfuse?

A

Never if Hgb > 10
Always if Hgb < 6
Usually if Hgb < 7
Otherwise if evidence of inadequate oxygen carrying capacity

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16
Q

Can you use intraoperative blood salvaging in OB?

A

Yes, in circumstances with massive hemorrhage and the blood bank is depleted or pt refuses blood bank. Anti-D immune globulin if mother is Rh -

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17
Q

Differential for oozing after 8 units pRBC

A 
Dilution coaguopathy (platelets first)
DIC (transfusion related, fetal demise, sepsis, AFE)
Also Acidosis and hypothermia should be corrected
18
Q

Pathway during major hemorrhage

A

Send labs: PT/INR, PTT, Fibrinogen, Hct/Hgb, Platelet, ABG. CMP if large resuscitation (hyperkalemia, hypocalcemia)
Replete 1:1:1.
Correct hypofibringenemia, thrombocytopenia, hypocalcemia, acidosis, hypothermia.
If all else fails, can try RFVII 90 mcg/kg x 2 Q20 minutes
If that fails, hysterectomy

19
Q

AFE syndrome

A 
Maternal collapse (hypotension, hypoxia, dyspnea, cardiopulmonary arrest, SZ, LOC), DIC
Unknown cause
20
Q

DIC in a pt with epidural

A

Treat coagulopathy. If no signs of spinal hemorrhage, then remove it. If it is bleeding, leave it to tamponade and get NS consult. If pt intubated, correct coagulopathy and remove it.

21
Q

Sheehan syndrome

A

Pituitary infarction after pregnancy/hypotension

Watch for hypotension (ACTH), no lactation (PH), hypothyroid (TRH)

22
Q

Death in OB: cause

A

Hemorrhage, HTN, Sepsis

23
Q

Level of analgesia for epidural

A

First Stage T10-L1

Second Stage S2-S4

24
Q

Treatment for hypotension after epidural associated with fetal distress

A
  • Hydration
  • Left uterine displacement
  • Elevate legs
  • O2 for Mom
  • Ephedrine / Phenylephrine boluses
25
Q

Mgmt of total spinal

A
  • Heralded by agitation, difficulty speaking, dyspnea
  • Airway support
  • Monitors
  • Epi if needed for hemodynamic support
26
Q

Fetal lie, presentation, position

A

Lie: Oblique, Longitudinal, Transverse
Presentation: Breech, Cephalic, Shoulder
Position: how it lies compared to maternal pelvis

27
Q

What to do about breech

A

External manipulation can be attempted
Vaginal or c/s depending on provider experience.
Usually c/s if other complications

28
Q

Timing of CO changes

A
  • Highest CO immediately PP
  • Returns to prelabor within 1 HR
  • 3 to 6 months for CV changes to revert
29
Q

Determinants of fetal oxygenation

A
  • Oxygen partial pressure
  • Oxygen carrying capacity
  • Uteroplacental blood flow
  • Placental diffusion
  • Placental oxygen utilization
30
Q

Determinants of uterine blood flow and percent of CO

A

Uterine blood flow = (Uterine Artery Pressure - Uterine Venous Pressure) / Uterine Artery Resistance
Uterus gets 10% of CO, 80% of which goes to placenta

31
Q

How to monitor the fetus

A

FHT invasive via scalp or non-invasive doppler

Uterine contractions invasive via transcervical catheter or noninvasive via abdomina muscular tone

32
Q

Normal FHR vs Fetal Compromise

A

120-160, beat to beat variability from 5 to 25 bpm. Early decels are ok

Late and Variable are not ok.
Loss of beat to beat variability is bad sign
If concern for compromise, fetal pH is rarely used now

33
Q

Decelerations

A

Early: Head compression
Late: Uteralplacental insufficiency
Variable: Cord compression, decrease 60 bpm and last 60 sec

34
Q

Meconium stained amniotic fluid

Meconium aspiration syndrome

A

Often associated with low fetal pH, but chicken or egg?

Meconium inactivates surfactant. Leads to pneumonia.
Improves in 72 hours, but may lead to pulm htn and persistent fetal circulation.

Do not suction/intubate vigorous baby, but do if distressed

35
Q

Uterus effects of volatile

A

if < 1.0 MAC no effect, at higher levels decreased contractility and increased blood loss

36
Q

APGAR

A 
Appearance
Pulse
Grimace
Activity
Respirations

Relate to mortality, not morbidity

37
Q

When are fetal heart tones heard

A

16 weeks

38
Q

Fetal tachycardia >160

A

Hypoxia, fever, thyrotoxicosis, tachydysrhymia, terbutaline

39
Q

Fetal bradycardia

A

Hypoxia, heart block, continuous head compression, hypothermia

40
Q

Fetal scalp pH

A

> 7.25 is reassuring

Anesthesia OB (5 decks)

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