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673 Advanced Anesthesia Principles > Week 6 OB Anesthesia Part 1 > Flashcards

Week 6 OB Anesthesia Part 1 Flashcards

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1
Q

Why is the parturient at a higher risk of difficult mask ventilation, difficult laryngoscopy, and difficult intubation?

A

Upper airway swelling due to:

  • Increased progesterone (as well as estrogen & relaxin) causing vascular engorgment
  • Increased extracellular fluid volume

APEX Unit 11 - Obstetrics, Part 1: Physiologic Respiratory Changes

Nagelhout Ch. 51, pg. 1177-1178

Torabi PPT, Slide 12

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2
Q

What pregnancy related hormone causes the ligaments in the ribcage to relax and allows the ribs to assume a more horizontal position?

A
  • Relaxin

APEX Unit 11 - Obstetrics, Part 1: Physiologic Respiratory Changes

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3
Q

Indicate the changes related to respiratory physiology in pregnancy

A
  • Increase O2 Consumption by 33%
  • Increase Minute volume by 50%
  • Increase Vt by 40%
  • Increase RR by 10% or same
  • Decrease FRC by 20%

APEX Unit 11 - Obstetrics, Part 1: Physiologic Respiratory Changes

Nagelhout Ch. 51, pg. 1177-1178

Torabi PPT, Slide 13

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4
Q

Indicate the changes related to cardiovascular physiology in pregnancy

A

APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes

Nagelhout Ch. 51, pg. 1176

Torabi PPT, Slide 7-9

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5
Q

Indicate the hematologic changes in pregnancy

A

APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes

Nagelhout Ch. 51, pg. 1177

Torabi PPT, Slide 9 & 11

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6
Q

How can we reduce the compressive effects of the gravid uterus and improve venous return and cardiac output?

A
  • Left displacement of the uterus - elevation of the mother’s right torso 15 degress (APEX says 15-30)

APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes

Nagelhout Ch. 51, pg. 1176-1177

Torabi PPT, Slide 10 - BOLD

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7
Q

The mechanism remains unclear, but a chronic exposure to ____________ during pregnancy causes an increased sensitivity to local and general anesthetics

This effect begins in the _________ trimester

A
  • progesterone
  • first

APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More…

Nagelhout Ch. 51, pg. 1178

Torabi PPT, Slide 15 - BOLD

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8
Q

Indicate the changes related to neurologic physiology in pregnancy

A

APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More…

Nagelhout Ch. 51, pg. 1178

Torabi PPT, Slide 15

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9
Q

Indicate the changes related to gastrointestinal physiology in pregnancy

A

APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More…

Nagelhout Ch. 51, pg. 1178

Torabi PPT, Slide 16

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10
Q

An elective c-section is planned for a patient with additional risk factors for aspiration - what medications should be considered for administration prior to delivery?

A
  • nonparticulate antacids
  • H2-receptor antagonists
  • metoclopramide

Nagelhout Ch. 51, pg. 1178

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11
Q

Indicate the changes related to renal physiology in pregnancy

A

APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More…

Nagelhout Ch. 51, pg. 1178-1179

Torabi PPT, Slide 19

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12
Q

Indicate the miscellaneous physiologic changes related to pregnancy

A

APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More…

Nagelhout Ch. 51, pg. 1178

Torabi PPT, Slide 18

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13
Q

Transfer of drugs from the maternal circulation to the fetal unit is determined primarily by _____________

A

Diffusion

APEX Unit 11 - Obstetrics, Part 4: The Uterus

Nagelhout Ch. 51, pg. 1179-1180

Torabi PPT, Slide 27 - BOLD

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14
Q

Most anesthetic agents cross the placenta, so it’s easier to learn which drugs do not cross. These include:

A
  • Heparin
  • Insulin
  • Glycopyrrolate
  • ND-MBA
  • Succinylcholine

Mnemonic: He Is Going Nowhere Soon

APEX Unit 11 - Obstetrics, Part 4: The Uterus

Nagelhout Ch. 51, pg. 1180

Torabi PPT, Slide 30-31 - BOLD

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15
Q

Describe the 3 stages of labor

A
  • Stage 1: beginning of regular contractions to full cervical dilation (10cm) - includes a latent and active phase
  • Stage 2: full cervical dilation to delivery of the fetus (perineal pain begins during this stage)
  • Stage 3: delivery of fetus to delivery of placenta

APEX Unit 11 - Obstetrics, Part 5: Stages of Labor

Nagelhout Ch. 51, pg. 1180

Torabi PPT, Slide 33-38 - BOLD

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16
Q

When labor progress no longer follows the normal pattern, it is considered a dysfunctional labor and may require the use of _____________ to augment contractions

A
  • oxytocin

APEX Unit 11 - Obstetrics, Part 5: Stages of Labor

Nagelhout Ch. 51, pg. 1180

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17
Q

What are the ASA NPO guidelines for obstetric analgesia?

A

A healthy, laboring mother may:

  • drink a moderate amount of clear liquids throughout labor
  • eat solid food up to the point a neuraxial block is placed

Pt. should remain NPO if surgical intervention with GA is likely

APEX Unit 11 - Obstetrics, Part 5: Stages of Labor

Nagelhout Ch. 51, pg. 1178

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18
Q

A neuraxial block may prolong the first stage of labor by what amount of time?

A

TRICKED YA HAHAHA SUCKAAA

  • It does NOT prolong the first stage of labor

APEX Unit 11 - Obstetrics, Part 5: Stages of Labor

Nagelhout Ch. 51, pg. 1188

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19
Q

True or false:

Neuraxial anesthesia in obstetric patients does NOT increase the need for a c-section

A

True

APEX Unit 11 - Obstetrics, Part 5: Stages of Labor

Nagelhout Ch. 51, pg. 1188

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20
Q

Describe labor pain during the first stage - include the following:

  • afferent pathway
  • spinal segments
  • quality of pain
A

Pain begins in lower uterine segment and the cervix

  • Afferent pathway: visceral C fibers
  • Spinal segments: T10-L1
  • Quality of pain: bad… jk… dull, diffuse, cramping

APEX Unit 11 - Obstetrics, Part 6: Labor Pain

Nagelhout Ch. 51, pg. 1180

Torabi PPT, Slide 32

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21
Q

Describe labor pain during the second stage - include the following:

  • afferent pathway
  • spinal segments
  • quality of pain
A

Additional pain impulses from the vagina, perineum, and pelvic floor

  • Afferent pathway: somatic - pudendal nerve
  • Spinal segments: S2-S4
  • Quality of pain: sharp, well localized

APEX Unit 11 - Obstetrics, Part 6: Labor Pain

Nagelhout Ch. 51, pg. 1180

Torabi PPT, Slide 32

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22
Q

What are the consequences of uncontrolled pain during labor?

A
  • increased maternal catecholamines Increase hypertension & reduced uterine blood flow
  • maternal hyperventilation Increase left shift of oxyhgb curve & reduced O2 delivery to the fetus

APEX Unit 11 - Obstetrics, Part 6: Labor Pain

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23
Q

What effect does progesterone have on cardiovascular physiology?

A
  • Increased RAAS activity Increase increased blood volume, increased cardiac output
  • Vascular smooth muscle relaxation Increase decreased SVR and PVR, increased blood flow

APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes

Nagelhout Ch. 51, pg. 1176

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24
Q

What effect does progesterone have on respiratory physiology?

A
  • It is a respiratory stimulant and increases minute ventilation by up to 50%
  • This causes a decrease in maternal PaCO2 (28-32 mmHg)

APEX Unit 11 - Obstetrics, Part 1: Physiologic Respiratory Changes

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25
Why does cardiac output increase during labor and immediately after delivery?
* There is an "autotransfusion" of blood into central circulation from the contracting uterus | CO increases as much as 80% above prelabor values ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes Nagelhout Ch. 51, pg. 1176 Torabi PPT, Slide 7-8
26
Cardiovascular changes in the parturient begin as early as __________ and gradually return to baseline within _________ after delivery
* week 4 of pregnancy * 14 days ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes Nagelhout Ch. 51, pg. 1176 Torabi PPT, Slide 7
27
At term, the uterus receives approximately ________ % of cardiac output
* 10 | ~700-900 mL/min ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes Nagelhout Ch. 51, pg. 1176 Torabi PPT, Slide 7
28
When should you seek consultation for a systolic murmur in the parturient?
* murmur is grade 3 or greater * murmur is accompanied by chest pain or syncope ## Footnote Nagelhout Ch. 51, pg. 1176 Torabi PPT, Slide 9
29
What are the signs and symptoms of aortocaval compression?
* **tachycardia** * **vasoconstriction of lower legs** * **hypotension** ## Footnote Nagelhout Ch. 51, pg. 1176-1177 Torabi PPT, Slide 10 - **BOLD**
30
Due to the hypercoagulable state of pregnancy, these women are at an increased risk for _____________
* thromboembolic events ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes Nagelhout Ch. 51, pg. 1177 Torabi PPT, Slide 11
31
The platelet count remains stable until 3rd trimester when it may __________ slightly
* decrease ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Cardiovascular Changes Nagelhout Ch. 51, pg. 1177 Torabi PPT, Slide 11
32
Overall, the WBC tends to ___________ in pregnancy
* rise | 3rd trimester mean of 10,500 and 20,000-30,000 in labor ## Footnote Nagelhout Ch. 51, pg. 1177 Torabi PPT, Slide 11
33
Upper airway swelling in pregnancy can narrow the glottic opening; what sized ETT should be used?
* 6.5-7.0 ## Footnote Nagelhout Ch. 51, pg. 1178 Torabi PPT, Slide 12
34
The changes in lung volumes & capacities during pregnancy, combined with an increased oxygen consumption can lead to rapid ______________
* **desaturation during apnea** ## Footnote Nagelhout Ch. 51, pg. 1178 Torabi PPT, Slide 13 - **BOLD**
35
Why is there a decrease in the volume of the epidural and subarachnoid spaces during pregnancy?
* Epidural vein engorgement ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More... Nagelhout Ch. 51, pg. 1178 Torabi PPT, Slide 15
36
______________ may result in a mechanical obstruction to outflow through the pylorus, decreased gastric emptying, and increased intragastric pressure
* **Upward displacement of the stomach by the gravid uterus** ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More... Nagelhout Ch. 51, pg. 1178 Torabi PPT, Slide 16 - **BOLD**
37
What effect does increased levels of progesterone have on gastrointestinal physiology during pregnancy?
* **Decrease gastric motility** * **Decrease in lower esophageal sphincter tone** ## Footnote APEX Unit 11 - Obstetrics, Part 2: Physiologic Changes - Neuro, GI, Renal & More... Nagelhout Ch. 51, pg. 1178 Torabi PPT, Slide 16
38
What 3 musculoskeletal changes occur in pregnancy?
* increased lumbar lordosis * increasingly mobile/relaxed pelvic joints * diastasis recti ## Footnote Torabi PPT, Slide 20
39
Because it is a low resistance system, uterine blood flow is primarily dependent on _____________
* maternal MAP & cardiac output | Intervillous blood flow is NOT autoregulated ## Footnote APEX Unit 11 - Obstetrics, Part 4: The Uterus Nagelhout Ch. 51, pg. 1179-1180 Torabi PPT, Slide 22-23
40
Name several factors that decrease uterine blood flow
**Decreased uterine arterial pressure** * sympathectomy * hemorrhage/hypovolemia * aortocaval compression **Increased uterine venous pressure** * uterine contractions * valsava maneuver * vena cava compression **Increased uterine vascular resistance** * endogenous vasoconstrictors (catecholamines) * exogenous vasoconstrictors (phenylephrine > ephedrine) ## Footnote APEX Unit 11 - Obstetrics, Part 4: The Uterus Torabi PPT, Slide 24 - **BOLD**
41
The umbilical cord contains three blood vessels: * one large ____________ * two smaller __________
* **umbilical vein** - carries oxygenated blood to fetus * **umbilical arteries** - carries CO2 and waste from fetus ## Footnote Torabi PPT, Slide 25 - **BOLD**
42
What is the effect of neuraxial anesthesia on uterine blood flow?
**Increased blood flow:** * pain relief * decreased SNS activity * decreased hyperventilation **Decreased blood flow:** * hypotension from blook * unintentional IV injection of LA and/or epi ## Footnote Torabi PPT, Slide 26 - **BOLD**
43
List 4 factors that favor placental transfer of drugs via diffusion
* Low molecular weight (<500 daltons) * **High lipid solubility** * Non-ionized * Non-polar ## Footnote APEX Unit 11 - Obstetrics, Part 4: The Uterus Nagelhout Ch. 51, pg. 1179-1180 Torabi PPT, Slide 27 - **BOLD**
44
____________ is the drug of choice for epidural analgesia and a decompensating fetus because it does not participate in ion trapping
* **Chloroprocaine** | amino-ester LA rapidly metabolized by ester hydrolysis ## Footnote Torabi PPT, Slide 29 - **BOLD**
45
What 3 elements can result in a difficult, painful labor?
* **fetal position/size** * **effectiveness of contractions** * **inadequate pelvic outlet** ## Footnote Nagelhout Ch. 51, pg. 1180 Torabi PPT, Slide 32 - **BOLD**
46
How do you determine Estimated date of delivery?
1. Figure out last menstrual period 2. Add 280 days to LMP
47
What is Naegele's Rule?
1. Add 7 days to LMP 2. Substract 3 months 3. Add 1 year
48
What weeks are each of the Trimesters?
1st Trimester: 0-12 weeks 2nd Trimester: 13-28 weeks 3rd Trimester: 29-40 weeks
49
Tx of Supine HoTN syndrome (Aortocaval)?
* Left uterine displacement * Tilt OR table left 15-30 degrees
50
Based on **Respiratory/Lung volume changes**, what are you concerned for in the Pregnant patient?
**Rapid desaturation when apneic**
51
What hepatic & pharmacokinetic change occurs during pregnancy? Should you be concerned?
Decrease Serum pseudocholinesterase activity by 30% * No significant prolongation of Remifenanil or Succinycholine
52
Pregnancy increases the risk of what hepatic related disease? Due to what?
Gallbladder disease * â–³ in Bile * Decrease emptying of gallbladder
53
Describe the pain and where it comes from for the 1st stage of Labor
Non-localized aching/cramping * Type-C fibers (T10-L1)
54
Describe the pain and where it comes from for the 2nd stage of Labor
Localized & Sharp * Somatic (S2-S4)
55
Elements that result in difficult & painful labor? | 3
1. Fetal position/size 2. Ineffective contractions 3. Poor pelvic outlet
56
1st stage of labor consists of what?
2 Phases 1. Latent Phase: onset of labor 2. Active Phase: Begins @ 2-3 cm dilated
57
2nd stage of labor consists of what elements?
10 cm dilated -> Delivery
58
3rd Stage of labor consists of what element(s)
Delivery of the placenta
59
Normal FHR?
110-160 bpm
60
What is considered tachycardia in a term baby?
>160 BPM
61
What are some causes of tachycardia in a fetus? | 5
* Fetal Asphyxia * Fetal Arrhythmias * Maternal Fever * Chorioamnionitis * Drugs administed to mother (Terbutaline/Atropine)
62
Best indicator of fetal well-being?
FHR variability
63
What are the levels of variability?
* Minimal: < 5 bpm * Moderate: 6-25 bpm * Marked: > 25 bpm
64
What types of FHR decelerations are there?
1. Early 2. Variable 3. Late
65
What can cause an early deceleration?
Compression of fetal head -> vagal stimulation
66
What can cause an late deceleration?
Uteroplacental insufficiency (Non-reassuring)
67
What can cause variable decelerations?
Umbilical cord compression
68
What is Veal Chop?
V: variable & C: compression E: early decel & H: head compression A: accelerations & O: OKAY! L: late decels & P: placental insufficiency
69
What dose and consequences may be experienced with ketamine administration to the mother?
**>1mg/kg** * Neonatal depression * Muscular hypertonicity * Decrease APGAR scores
70
What conditions might early initiation of neuraxial anesthesia be considered for Labor? | 6
* Morbid obesity * Severe Scoliolis * Difficult airway * Multi-gestational * Severe preeclampsia * Grandmultiparity
71
Absolute CI to neuraxial anesthesia? | 5
* Pt refusal * Unable to cooperate * Severe hypovolemia * Uncorrected coagulopathy * Increase ICP
72
Relative CI to neuraxial anesthesia?
* Pre-existing CNS disease * Chronic/severe HA or back pain * Bacteremia * Severe stenotic lesions
73
Pros/Cons of Bupivacaine in OB?
Pro: Long duration Con: Cardiotoxicity in large doses
74
Pros/Cons of Lidocaine in OB?
Pro: Rapid onset, intermediate duration Cons: Not for use in subarachnoid, Cauda equina syndrome
75
Pros of Chloroprocaine in OB?
* Rapidly metabolized * Good for emergency C/S * Systemic toxicty rare * Almost none crosses placenta
76
Cons of Chloroprocaine in OB?
Reduce quality/duration of epidural: * Morphine * Fentanyl
77
Pros/Cons of Ropivacaine in OB?
Pros: Less cardiotoxic Cons: Less motor block
78
Dose of Duramorph for Neuraxial anesthesia?
Spinal: 200 mcg (0.2mg) Epidural: 2-4 mg
79
S/E of neuraxial Duramorph?
* Pruritis * N/V * Urinary retention
80
Complications from regional anesthesia? | 10
* HoTN * N/V * PDPH * LAST * Total Spinal * Subdural injection * Cardiac Arrest * Neurologic injury * Epidural Hematoma * Cauda equina syndrome
81
Onset for epidural hematoma?
0 - 2 days
82
Symptoms of epidural hematoma?
* Motor/Sensory deficits * â–³ in bowel/bladder function * Back pain
83
Treatment for epidural hematoma?
Immediate surgical drainage
84
Onset and symptoms of Subdural injection?
* 10-25 min * Excessively High sensory block (little motor) * Unilateral * HoTN
85
S/S of PDPH
* **HA while standing/sitting** * Nausea * Vertigo * Low Back pain * Frontal/occipital pain -> neck/shoulders
86
What ↑ risk for PDPH?
* **Spinal blocks** * Beveled needles (Quincke) * Horizontal needle orientation
87
Your parturient has an epidural catheter but needs to be converted for surgical anesthesia, how do you increase your block from T10 to T4?
Administer 10-15mL
88
Your parturient needs GETA, what will you ensure to do? | 6
* Preoxygenate 3 min * Ramp pt * RSI * Cricoid pressure (10N awake -> 30N @ LOC) * Delay induction until prepped/draped * Confirm ETT prior to incision
89
Standard induction/NMB agent and dosages for GETA in OB?
Propofol: 2-2.5mg/kg Succinylcholine: 1-1.5mg/kg
90
What is the NMB of choice in pregnant pts and why?
Succinylcholine * Considered full stomach
91
Uterine blood flow @ term?
700 mL/min or 10% of CO
92
What % of uterine blood flow goes to the placenta?
80% or ~560mL/min
93
Standard test dose drugs, %, & mg?
* Lidocaine 1.5% - 15mg/mL * Epinephrine 1:200,000 - 5 mcg/mL
94
What drug is used for spinal anesthesia?
Hyperbaric 0.75% Bupivacaine
95
Dose range for a spinal anesthetic?
12.5-15 mg of 0.75% Bupivacaine (~1.5-2mL)

673 Advanced Anesthesia Principles (7 decks)

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