Anesthesia For Operative Delivery (Exam III) Flashcards
1
Q
What is Macrosomia?
A
Fetus/Newborn w/ excessive birth weight
2
Q
What is TOLAC?
A
Trial of Labor after Cesarean
3
Q
What is VBAC?
A
Vaginal Birth after Cesarean
4
Q
What is PPH?
A
Post-partum Hemorrhage
5
Q
What is SAB?
A
Spontaneous Abortion
Or subarachnoid block.
6
Q
What are indicators for operative vaginal delivery?
A
- Bad FHR variability
- Maternal exhaustion
- Arrested Descent
7
Q
If a denser sensory block is necessary for operative vaginal delivery, what medications can be used?
A
Epidural:
- Lidocaine 2% 5-10mls
- 2-Chloroprocaine 2-3% 5-10mls
8
Q
What is the most common majory surgery in the USA?
A
C-section
9
Q
Maternal mortality is _____ times greater with a c-section vs vaginal delivery.
A
10x greater
10
Q
What are anesthesia complications that can contribute to mortality in converting to a C-section from a vaginal birth?
A
- Pulmonary aspiration
- Edematous/friable airways
- Inadequate ventilation requiring GETA
11
Q
What factors are contributing to an increased national rate of c-sections?
A
- ↑ maternal age
- Obesity
- Fetal macrosomia
- ↓ TOLAC attempts
- Fear of instrumented vaginal deliveries.
12
Q
What are the maternal indications for c-section?
A
13
Q
What are the fetal indications for c-section?
A
14
Q
What type of c-section incision is used for emergencies?
A
Midline incisions
Umbilicial to pubic symphysis.
15
Q
What are the three different types of c-section incisions?
A
- Low Transverse (best if possible)
- Vertical
- Classical (highest risk)
16
Q
With what type of c-section incision is TOLAC contraindicated?
A
Classical incision
17
Q
With what type of c-section incision is TOLAC possible?
A
Low-Transverse Incision
18
Q
Why does GETA potentiate blood loss?
A
Due to GETA vasodilation.
19
Q
What is the most common c-section complication?
A
Hemorrhage
Usually due to uterine atony → oozy uterus.
20
Q
What complications (other than hemorrhage) can happen in c-sections?
A
- Infection
- Uterine/cervical lacerations
- Bladder damage
- Fetal damage
- Hysterectomy
21
Q
What is the terminology for abnormal placental invasion of surrounding tissues?
A
Accreta → Increta → Percreta
22
Q
_______ ______ is when the placenta develops in such a way that it blocks the baby’s ability to exit out of the cervix & vagina.
A
Placenta Previa
23
Q
What risk occurs with external cephalic version?
A
↑ risk of uterine rupture
24
Q
What is the preferred anesthetic technique for a c-section?
A
Neuraxial Anesthesia
25
Previous c-sections indicates an increased risk of ______.
bleeding
26
What sensations are normal even with a spinal anesthetic?
pushing, pulling, tugging, & pressure
27
Which two drugs need to be stocked and ready to go in the OB operating room?
Propofol & Succinylcholine
*Be ready to RSI*.
28
What three medications are given to prevent (or diminish consequences) aspiration in parturients?
- Famotidine 20mg IV
- Metoclopramide 10mg IV
- Na⁺ Citrate (Bicitra) 30mLs PO
29
What type of drug is famotidine?
H2 receptor antagonist that decreases gastric acid production.
30
What is the onset & peak of famotidine?
Onset: 30 min
Peak: 60 - 90 min
31
How does metoclopramide work?
- ↓ stomach volume via increased motility.
- increased LES tone
- ↓ N/V
Dopamine D2 antagonist
32
When should metoclopramide be administered?
15-30 min prior to anesthesia start
33
What type of drug is Bicitra?
Non-particulate antacid that decreases gastric acidity to > 6pH
34
When should Bicitra be administered?
20-30 min before going to the OR.
35
What antibiotic given to parturients should be administered slowly due to risk of N/V?
Azithromyicin
36
What things/factors put a parturient at risk for higher blood loss?
- GETA
- Abnormal placenta
- Unscheduled C-section after attempted vaginal
- Multiparous
- Multiple past c-sections
37
What monitoring equipment is necessary before spinal placement?
At minimum:
- FHT
- Mom's BP
- Pulse oximetry
38
Why is versed "discouraged" but not contraindicated?
- Crosses placenta & sedates baby
- Amnestic effects on bonding
39
Is oxygen necessary for an elective c-section?
Not necessarily (but is typically done).
40
What is an ideal spinal dose of morphine?
100 - 150mcg
41
What is an ideal spinal dose of Fentanyl?
5 - 10mcg
42
What is an ideal dose of epidural morphine?
3mg
43
What are some disadvantages to C-section?
- N/V
- Diaphragm stimulated
- HoTN
44
What causes referred shoulder/chest pain during a c-section?
Uterus being pulled out
45
How is the diaphragm stimulated during a c-section?
Irrigation can stimulate the diaphragm & cause N/V, cold, pain sensations.
46
What reflex can be activated during a c-section?
Bezold Jarisch Reflex
47
What are the triad of symptoms associated with the Bezold-Jarisch Reflex?
- Vasodilation
- Hypotension
- Bradycardia
48
What causes the Bezold-Jarisch reflex?
Mechanoreceptors sensing a hyperdynamic LV w/ low preload.
49
Which drug can be administered to prevent the bezold-jarisch reflex associated with a spinal block?
Ondansetron 4mg
*Antagonizes 5HT-3 receptors & prevents activation of BJR*.
50
What position should a patient be in after a spinal block?
Slight (10°) head up
*Bed can also be tilted left for slight LUD*.
51
Which colloid has an increased risk for anaphylaxis?
Hetastarch
52
What is the IM dose of ephedrine for hypotension?
25mg
53
What acid-base imbalance of the umbilical artery can be caused by ephedrine?
Metabolic Acidosis
54
Which of the following readily crosses the placenta:
Ephedrine
Phenylephrine
Ephedrine
55
Hyperbaric Lidocaine (5%) is not commonly seen due to risk of ____.
TNS
Transient Neurologic Syndrome (leg & back pain 24-48 hrs after spinal).
56
We want our spinal anesthetic to reach what sensory level?
T4
57
What is the most common local anesthetic used for spinals?
0.75% bupivacaine
58
Do spinally administered opioids increase or decrease PONV occurrence?
Both.
Can decrease occurrence due to decreased sensations that trigger PONV.
59
What is the dose of Fentanyl for SAB?
10 - 25mcg
60
Is early or late respiratory depression seen with fentanyl?
early
61
What is the dose of morphine for SAB?
100 - 150mcg
62
What is the onset and duration for morphine administered spinally?
Onset: 30 - 60 min
Duration: 12 - 24 hrs
63
Will respiratory depression be seen earlier or later with morphine administered via SAB?
Later (6-18 hrs after!)
64
How is the pruritus associated with SAB morphine treated?
Nalbuphine or Butorphanol
Naloxone or Naltrexone
65
What is the dose of an "epi wash"?
0.1 - 0.2mg epinephrine administered in a SAB.
66
What is the purpose of an "epi wash"?
Can prolong block by 15% or more
67
What dose of Precedex is utilized in spinals?
5-10 mcg
68
What is the purpose of spinally administered Precedex?
- Prolongs sensory & motor blockade
- Post-op pain control
- Minimizes shivering
69
What are the adverse effects associated with spinally administered dexmedetomidine?
Bradycardia & Hypotension
70
Epidural medication doses are approximately _____ times that of spinal doses.
5 - 10 x
71
Are spinals or epidurals better for C-sections?
Spinals (more reliable and dense)
72
What VAA can be added to a patient with an epidural who is undergoing an unplanned C-section?
N₂O
73
IV anesthetics such as ______ or ______ are commonly used as adjuncts to epidurals for patients undergoing unplanned c-section.
ketamine ; precedex
74
2% Lidocaine is just as fast as chloroprocaine when what additive is added to it?
Na⁺ Bicarbonate
75
What dose of 1% Lidocaine is utilized for spinal blocks for c-sections?
Trick Question. Concentrations less than 2% Lidocaine are inadequate for c-section anesthetics.
76
What metabolized chloroprocaine?
Pseudocholinesterases
77
What drug can decrease the efficacy of epidural morphine? Why?
2-Chloroprocaine
Antagonizes μ and κ opioid receptors
78
Which dose of bupivacaine **IS NOT** utilized in epidurals?
0.75%
↑ Only for spinals
79
What dosage of bupivacaine is used for epidurals?
0.5%
80
What dosage of ropivacaine is common for epidurals?
0.5%
81
Compare the cardiac toxicity profiles of ropivacaine & bupivacaine?
Ropivacaine is less cardiotoxic than bupivacaine
82
Between fentanyl and morphine, which opioid administered spinally provides for a more dense block?
Fentanyl
83
What ratio of dexmedetomidine to LA is typically used in epidurals?
4-5 mcg/mL of precedex for each 1mL of LA.
Ex. 20mL of LA + 80 - 100mcg Precedex
84
How does Na⁺ bicarb helps speed up onset?
Shifts local anesthetic to more **non-ionized state**.
very useful speeding up epidural to avoid GETA.
85
Your patient has an epidural in place and is being converted from a normal labor to a c-section. The epidural is unilateral, how can this be fixed?
Replaced the catheter if possible
86
Your patient has an epidural in place and is being converted from a normal labor to a c-section. The epidural is patchy, how can this be fixed?
- Supplement w/ adjuncts (ex. 50mcg Fentanyl)
87
How much local anesthetic will you typically use to "top off" an epidural for a c-section?
10 - 15mls
88
What is the Allis Test?
Pinch patient with clamps to assess quality of epidural anesthesia.
- If the patient can't feel clamps then you're good for surgical incision.
89
Why should your epidural dosing be less with a combined spinal epidural (CSE) ?
Hole through dura mater can result in medication going from epidural to spinal space.
90
What are three reasons that one might have to convert to general anesthesia for a c-section?
- Fetal Distress
- Maternal Hemmorrhage w/ hypovolemia
- Neuraxial Anesthetic not possible
91
What are some reasons that neuraxial anesthesia may not be possible for c-section patients?
- Outright refusal
- Infection
- Coagulopathy / thrombocytopenia
92
Does GETA increase or decrease maternal mortality?
Increase
93
How does GETA affect apgar scores?
↓ Apgar scores associated with GETA
94
How can potential anesthesia recall occur with GETA for delivery?
- ↓ MAC for delivery due to loss of uterine tone & concurrent bleeding
95
What is the dose of succinylcholine?
1 - 1.5 mg/kg
96
What induction agents are used for emergent c-sections?
Propofol + Succ
97
What size ETT is used for c-sections?
6 - 7 mm ETT (remember that airway is friable & edematous)
98
What other tube is placed (other than ETT) for a GETA c-section?
orogastric tube (suction out the stomach)
99
In regards to a c-section delivery, when is pitocin/oxytocin started?
**AFTER** delivery
*Needs to be announced to whole room that its being started*.
100
Less VAA = _______ uterine tone.
increased (results in less bleeding)
101
What is MAC value decreased to after delivery of the baby?
0.5 - 0.75 MAC
102
Opioids are given ____ delivery in order to decrease risk of neonate respiratory depression.
**After**.
103
What paralytic is used after Succinylcholine has worn off?
Trick question. Use VAA to drive muscle relaxation
104
Maternal hypocapnia results in what oxygenation change for the fetus?
↓ O₂ delivery due to leftward oxyhemoglobin dissociation curve shift.
105
Maternal hypercapnia results in bradycardia or tachycardia?
Tachycardia
106
What would cause you to do a deep extubation on a parturient patient?
*Trick Question*. Extubate patient awake. Still considered a full stomach.
107
What are the three drugs used to treat uterine atony?
- Pitocin
- Methergine (methylergonovine)
- Hemabate (Carboprost)
108
What symptoms from a Pitocin drip would prompt you to slow the infusion?
Hypotension & flushing
109
When is Pitocin started after delivery?
What dosage is used?
- After umbilical cord is cut
- 20u in NS bag (drip in slowly)
110
What is the dose of Methergine (methylergonovine)?
0.2 mg IV/IM
111
________ would cause one to be very careful using Methergine (methylergonovine).
Hypertension
112
What is the dose of Carboprost (Hemabate)?
250mcg IM
113
What drug is given if a patient is still bleeding after Pitocin administration?
Carboprost (Hemabate)
114
What medical condition would make you cautious in giving Hemabate?
Asthma
115
What factors associated with C-sections result in PONV?
- Hypotension
- Surgical Stimulation
- Uterotonics
116
How does hypotension result in PONV?
- Cerebral hypoperfusion → medullary vomiting center stimulation
- Gut ischemia → emetogenic substances released from intestines
117
Why does surgical stimulation result in PONV?
VAGAL Stimulation
- Uterine exteriorization
- Intra-abdominal manipulation
- Periotneal tract stimulation
118
GETA for emergent c-section results in a very high risk for ______.
recall / hemorrhage
119
What drug can be given to help prevent recall in emergent c-sections? When is this given?
2mg Midazolam **as soon as the baby is out**.
120
Is it better to have block that is too high or too low?
too high
*Can supplement w/ O₂*
121
What should anesthesia do if a block is excessively high? (loss of consciousness, loss of respiratory drive, refractory HoTN)
Convert to GETA
