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Anesthesia Practice > AP 3 Final LAST ONE!!!!!!!!! > Flashcards

AP 3 Final LAST ONE!!!!!!!!! Flashcards

1
Q

What does “gravida” mean?

A

Number of times a patient has been pregnant

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2
Q

What does “parity” mean?

A

Number of babies born

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3
Q

What do the 4 numbers listed under “parity” on a patient’s chart mean?

A
  1. Full term births
  2. Preterm births
  3. Losses (spontaneous or otherwise)
  4. Living children
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4
Q

What is a baby considered “full term” when calculating gestational age?

A

Full term starts at 38 weeks gestation

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5
Q

A woman’s blood volume increases by __% during pregnancy

A

40

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6
Q

A woman’s heart rate increases by __% during pregnancy

A

15-20

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7
Q

A woman’s stroke volume increases by __% during pregnancy

A

25%

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8
Q

A woman’s cardiac output increases by __% during pregnancy

A

50%

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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

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10
Q

How much does a woman’s cardiac output increase immediately after delivery?

A

As much as 80% (12-14L/min)

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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

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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.

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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

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14
Q

How does minute ventilation change in a pregnant woman?

A

Increases due to increased RR and TV

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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

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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

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17
Q

How does the airway change during pregnancy?

A

Capillary engorgement of the mucosa causes swelling and difficult DL views

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18
Q

What airway management techniques should be avoided in pregnant women?

A

Nasal instrumentation due to swollen and friable tissue

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19
Q

What pregnancy condition can cause the airway to worsen quickly over a couple hours?

A

Pre-eclampsia

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20
Q

Most common cause of anesthesia-related mortality in pregnant patients

A

Loss of airway

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21
Q

Major GI changes in pregnant women (3)

A
  1. Delayed stomach emptying (due to uterus displacing stomach)
  2. GERD (due to GE junction loosening)
  3. Stomach contents are more acidic (placenta secretes gastrin)
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22
Q

Due to the GI changes of pregnant women, all of these patients are treated as…

A

Full stomach

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23
Q

GI changes of pregnant women cause them to be at significant risk of…

A

Aspiration

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24
Q

What should you consider when picking ETT sizes for pregnant women

A

Pick slightly smaller size due to airway swelling

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25
Q

Due to their GI changes, what medication should pregnant women take before surgery

A

Sodium citrate (bicitra) - makes stomach contents less acidic

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26
Q

What hematologic condition is common during pregnancy?

A

Anemia

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27
Q

Why are pregnant women prone to anemia?

A

Plasma volume increases by 40% and red cell mass increases by 20%, so there is a slightly reduced red cell concentration in the blood

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28
Q

Normal Hgb levels for pregnant patients

A

11-12g/dL

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29
Q

Normal Hct for pregnant patients

A

35%

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30
Q

How does platelet count change in a pregnant woman

A

Decreases

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31
Q

How does clotting change during pregnancy? Why?

A

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.

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32
Q

Since pregnancy is a “hypercoagulable state” - pregnant woman are more at risk for…

A

DVT

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33
Q

Oxygen consumption increases by __% in pregnant women

A

20%

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34
Q

How does PaCO2 change in pregnant women

A

Decreases

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35
Q

How does pH change in pregnant women

A

Unchanged

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36
Q

How do placental hormones affect the mother’s glucose levels

A

Can lead to hyperglycemia, can cause gestational diabetes

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37
Q

How does plasma cholinesterase levels change in pregnant women

A

Decreases - but not enough to affect succinylcholine clearance

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38
Q

How do plasma protein concentrations change in pregnant women

A

Decrease via dilution

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39
Q

How long after conception does there begin to be a decrease in MAC levels for the pregnant patient?

A

8-12 weeks after gestation

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40
Q

How does the spread of neuraxial medications change during pregnancy?

A

Increases

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41
Q

Number one cause of pregnancy-related mortality worldwide

A

Hemorrhage

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42
Q

Number one cause of pregnancy-related mortality in the US

A

Cardiovascular disease

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43
Q

Anesthesia related maternal mortality is the __th leading cause of maternal mortality

A

10th

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44
Q

Causes of anesthesia-related maternal mortality

A

Failure to secure the airway is the top cause…others include

  • pulmonary aspiration
  • high spinal
  • LAST due to IV injection of local
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45
Q

Safest and most effective medical intervention for labor pain

A

Lumbar epidural

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46
Q

Can opioids be given for labor pain?

A

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

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47
Q

When is a patient in “labor”

A

When they are having uterine contractions that result in a cervical change

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48
Q

What is stage 1 of labor

A

Dilation of cervix to 10cm

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49
Q

Stage 1 of labor is broken down into what 3 phases

A
  1. Latent labor
  2. Active labor (accelerated cervical change that beings at 4-6cm)
  3. Transition into stage 2 of labor
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50
Q

Where does the pain from stage 1 of labor originate?

A

Visceral pain from uterus and cervix, innervated by T10-L1

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51
Q

Stage 2 of labor

A

Fetus passing through cervix and into vaginal canal

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52
Q

Where does the pain from stage 2 of labor originate?

A

Somatic pain from compression of perineal tissue, innervated by S2-S4

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53
Q

Stage 3 of labor

A

Delivery of the placenta

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54
Q

Sudden, severe pain during stage 3 of labor should cause concern for…

A

Uterine inversion

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55
Q

What is the Puerperal period of labor (stage 4)?

A

From after delivery of the placenta until return to non-pregnant physiology (usually 2-6 weeks after delivery)

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56
Q

Contraindications to neuraxial block

A

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)

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57
Q

There is a contraindication to a neuraxial block during what phase of labor

A

Complete dilation of the cervix during the 2nd stage of labor

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58
Q

Most painful stage of labor

A

2

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59
Q

When is an epidural for delivery normally placed?

A

After active labor has begun - can be placed any time after a patient is committed to labor

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60
Q

What can help prevent hypotension from epidural placement

A

Fluid bolus before or during placement

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61
Q

Patient history needed before placing an epidural for delivery

A
  • Age
  • Gravida
  • Parity
  • Gestation
  • Medical problems
  • Cervical exam
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62
Q

Physical exam needed before epidural placement for delivery

A
  • Vital signs (including temp)
  • Height
  • Weight
  • Airway
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63
Q

Labs needed before epidural placement for delivery

A
  • Platelet #
  • Hgb/hct
  • White count
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64
Q

What monitors are necessary to have on patient during epidural placement

A
  • Pulse ox

- BP every 5 minutes

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65
Q

What gauge are epidural needles used for delivery

A

17 or 18 gauge

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66
Q

Why is extra care and precision needed when assessing loss of resistance during epidural placement for a delivery

A

The ligaments are softer in pregnant women so loss of resistance can be more subtle

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67
Q

A test dose for an epidural tells us what?

A

If the epidural is in the intrathecal or intravascular space

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68
Q

Classic test dose for epidurals

A

3mls of Lidocaine 1.5% and 1:200,000 epi

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69
Q

Signs that an epidural catheter is intrathecal

A
  • Warmth in bottom
  • Numbness
  • Difficulty moving legs
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70
Q

Signs that an epidural catheter is intravascular

A
  • Ringing in ears
  • Numbness around mouth
  • Metallic taste
  • Increased HR within 30 seconds (usually to ~130bpm)
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71
Q

When dosing an epidural, what amount of local is incrementally injected?

A

3 or 5mL boluses

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72
Q

What local anesthetic is usually used for an epidural for delivery

A

Long acting agent such as bupivicaine or ropivicaine

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73
Q

Tools used to assess which dermatomes are blocked to pain after an epidural placement

A
  • Pinprick
  • Alcohol swabs
  • Ice
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74
Q

What is a CSE?

A

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)

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75
Q

Benefits of CSE

A
  • Near-immediate pain relief

- Confirmation of epidural space

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76
Q

Risks of CSE

A
  • Spinal headache

- Paresthesias

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77
Q

What is a subdural catheter?

A

When the epidural catheter ends up between the dura and the arachnoid

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78
Q

Risks of epidural placement

A
  • Inadvertent dural puncture
  • Hypotension (can affect fetus)
  • Failed block
  • IV/intrathecal injection
  • Nerve injury
  • Prolongation of stage 2 of labor
  • Epidural hematoma
  • Infection
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79
Q

What is an inadvertent dural puncture?

A

Also called a “wet tap” - when the epidural needle punctures the dura and CSF comes through

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80
Q

A wet tap dramatically increases the risk of…

A

Postdural puncture headache due to continual leakage of CSF

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81
Q

Definitive treatment for inadvertent dural puncture

A

Blood patch - epidural injection of blood

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82
Q

What treatments for inadvertent dural puncture should be tried first?

A
  • Lying flat
  • Caffeine
  • Pain pills
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83
Q

Complications of blood patch

A
  • Shooting pains in legs
  • Infection
  • New wet tap
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84
Q

What is done by the practitioner in the event of a wet tap?

A

Either…

1) The needle is removed and epidural placed at an adjacent level
2) Catheter is inserted into the intrathecal space

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85
Q

Indications for C-section

A
  • 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
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86
Q

Normal fetal heart rate

A

110-160bpm

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87
Q

Early decelerations in fetal heart rate during a contraction is often associated with…

A

Head compression as fetus moves toward delivery

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88
Q

Variable decelerations in fetal heart rate during a contraction can be associated with…

A

Uterine cord prolapse

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89
Q

Late decelerations in fetal heart rate during a contraction are suggestive of…

A

Fetal asphyxia during contractions

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90
Q

Anesthetic options available for c-section

A

Epidural, spinal, or general

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91
Q

What are neuraxial considerations for c-section?

A
  • Need T4 block to block peritoneal stimulation

- Need denser block than for labor

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92
Q

Mortality rates in c-sections are __ times greater with general than neuraxial anesthesia

A

17

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93
Q

Fetal transfer of general anesthesia induction drugs are all but inevitable if the delivery is delayed more than __ minutes after induction

A

2

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94
Q

What induction drugs are not transferred to fetus

A

Paralytics

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95
Q

What is a single spot spinal

A

A small gauge needle is inserted into subarachnoid space and meds are injected

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96
Q

Benefits of single shot spinal

A

Quick with no risk of large gauge dural punction

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97
Q

Risks of single shot spinal

A
  • High block

- Hypotension

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98
Q

Single shot spinals are contraindicated in pregnant patients with what disease

A

Multiple sclerosis

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99
Q

What local anesthetics are used in epidurals for a C-section

A

More concentrated locals…

  • Bupivicaine 0.5%
  • Lidocaine 2%
  • Chloroprocaine 3%
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100
Q

Effects of morphine in a spinal or epidural

A

Gives 24 hour improved pain control but delayed risk of respiratory depression

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101
Q

Monitors needed for c-section

A
  • ASA

- Fetal heart tones must be assessed and monitored after anesthesia is induced

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102
Q

First sign of hypotension in patient undergoing c-section under regional anesthesia

A

Nausea/vomiting

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103
Q

Reflexing the table so the uterus is at the bottom of the patient reduces the risk of…

A

Venous air embolism

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104
Q

What medication is given immediately after the baby is born in a c-section

A

Pitocin - reduces uterine atony and hemorrhage

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105
Q

Pain med considerations for the mother once the baby is delivered in a c-section

A

Epidural opiods are given. Can safely give more sedatives, narcs, etc since there is no longer a fear of fetal transfer

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106
Q

Anesthetic options for emergency c-section

A
  • If epidural is functioning and in place, dose it up

- If not, choose general or lateral spinal

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107
Q

Preparations necessary if a general anesthetic is chosen for an emergency c-section

A

Patient must be prepped and draped prior to induction of general anesthesia so that if induction goes badly, the fetus can be saved

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108
Q

Induction plan for emergency c-section

A

RSI with propofol and succinylcholine

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109
Q

How must volatile anesthetics be managed after the baby is delivered in a c-section?

A

Use MINIMAL volatile because volatile agents relax the uterus and contribute to uterine atony

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110
Q

In general, the patient feels more sensation during a c-section with what neuraxial method?

A

Epidural

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111
Q

When should you consider re-dosing catheter during c-section

A

1-1.5 hr after surgery start

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112
Q

If a single shot spinal wears off during c-section, what can be given for powerful pain management that will still preserve ventilation

A

Ketamine

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113
Q

Premature labor is labor that occurs between…

A

20 and 37 weeks gestation

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114
Q

Contributing factors to premature labor

A
  • Extremes of age
  • Inappropriate prenatal care
  • Increased physical activity
  • Unusual body habitus
  • Previous preterm delivery
  • Multiple pregnancies
  • Infection
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115
Q

Fetal complications of premature labor

A
  • Hypoxemia/asphyxia from umbilical cord compression
  • Inadequate surfactant levels
  • Intracranial hemorrhage due to poorly calcified cranium
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116
Q

When are surfactant levels adequate in fetuses

A

After 35 weeks

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117
Q

What is premature rupture of membranes (PROM)?

A

Leakage of amniotic fluid that occurs before the onset of labor

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118
Q

Predisposing factors for PROM

A
  • Short cervix
  • History of preterm labor
  • Infection
  • Multiple gestations
  • Polyhydramnios
  • Smoking
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119
Q

If PROM occurs, delivery is indicated if the the fetus is over __ weeks gestation

A

34

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120
Q

What is done if PROM occurs and the fetus is less than 34 weeks

A

Give prophylactic antibiotics and tocolytics to prevent labor for 5-7 days

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121
Q

Maternal complications from chorioamniotitis

A
  • Dysfunctional labor
  • Intraabdominal infection
  • Septicemia
  • Postpartum hemorrhage
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122
Q

Fetal complications from chorioamniotitis

A
  • Premature labor
  • Acidosis
  • Hypoxia
  • Septicemia
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123
Q

Clinical signs of chorioamniotitis

A
  • Fever over 38C
  • Maternal and fetal tachycardia
  • Uterine tenderness
  • Foul smelling/purulent amniotic fluid
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124
Q

Predisposing factors to uterine cord prolapse

A
  • Excessive cord length
  • Malpresentation
  • Low birth weight
  • Grand parity (over 5 births)
  • Multiple gestations
  • Artificial rupture of membranes
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125
Q

Diagnosis of uterine cord prolapse

A
  • Sudden fetal bradycardia

- Profound decelerations

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126
Q

Treatment of uterine cord prolapse

A
  • Immediate steep trendelburg or knees to chest

- Pushing of fetal part back into pelvis

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127
Q

Anesthetic method for uterine cord prolapse

A

General anesthesia for the c-section

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128
Q

Classic triad of signs of an amniotic fluid embolism

A
  1. Acute hypoxemia
  2. Hemodynamic collapse - severe hypotension
  3. Coagulopathy without obvious cause
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129
Q

Other s/s of amniotic fluid embolism

A
  • Pulmonary edema
  • Cyanosis
  • CV arrest
  • DIC
  • Fetal distress
  • Seizures
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130
Q

3 main pathophysiological manifestations of amniotic fluid embolism

A
  1. Acute pulmonary embolism
  2. DIC
  3. Uterine atony
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131
Q

Treatment for amniotic fluid embolism

A
  • Aggressive CPR and supportive care

- Immediate c section

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132
Q

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
A

B. Hypertension

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133
Q

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

A. Amniotic fluid embolism

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134
Q

What is placenta previa

A

When the placenta covers the internal cervical opening

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135
Q

Risk factors for placenta previa

A
  • Scarring of uterine wall by previous pregnancies, surgeries, abortions, etc.
  • Multiple pregnancy (twins, triplets, etc)
  • Many previous pregnancies
  • Abnormally developed uterus
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136
Q

Symptoms of placenta previa

A
  • Painless vaginal bleeding

- Episodic bleeding

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137
Q

Until proven otherwise, all pregnant patients with vaginal bleeding are assumed to have…

A

Placenta previa

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138
Q

Anesthetic management for placenta previa of an unstable patient

A

General anesthesia

  • 2 large bore IVs
  • Vigorous volume replacement
  • Crossmatch 2 units
  • Central line good for rapid transfusion and monitoring
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139
Q

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

A

D) GA INDUCTION W/ 0.5 MG/KG KETAMINE, INTUBATION W/ 1-1.5 MG/KG SUCCINYLCHOLINE

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140
Q

Causes of antepartum hemorrhages

A

1) Placenta previa

2) Placental abruption

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141
Q

What is placental abruption

A

Separation of normal placenta after 20 weeks of gestation causing fetal distress

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142
Q

Most common cause of intrapartum fetal death

A

Placental abruption

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143
Q

Risk factors for placental abruption

A
  • HTN
  • Trauma
  • Short umbilical cord
  • Multiparity
  • Prolonged PROM
  • Tobacco use
  • ETOH abuse
  • Cocaine use
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144
Q

Symptoms of placental abruption

A
  • Painful vaginal bleeding
  • HTN
  • DIC
  • Uterine tenderness
  • Increased uterine activity
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145
Q

Diagnosis of placental abruption

A
  • U/s to exclude placenta previa

- Amniotic fluid is port wine colored

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146
Q

With mild to moderate placental abruption, fibrinogen levels are reduced to…

A

150-250 mg/dL (normal 200-500)

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147
Q

With severe placental abruption, fibrinogen levels are reduced to…

A

Below 150

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148
Q

Anesthetic management of placental abruption

A
  • Fetal heart rate monitoring
  • Large gauge IVs
  • Aggressive volume resuscitation
  • Check HCT and coagulation
  • Type and cross units
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149
Q

If a pregnant patient is unstable and needs blood but you don’t know her blood type, what type should you give?

A

O negative

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150
Q

Cause of peripartum hemorrhage

A

Uterine rupture

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151
Q

S/s of uterine rupture

A
  • Constant pain
  • Hypotension
  • Fetal distress
  • Ineffective contractions
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152
Q

Most reliable sign of uterine rupture

A

Fetal distress

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153
Q

Treatment for uterine rupture

A

Volume resuscitation and immediate laparotomy under general anesthesia

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154
Q

Even with epidural anesthesia, uterine rupture often presents as…

A

Abrupt onset of continuous abdominal pain with hypotension

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155
Q

What is a retained placenta

A

When fragments of placenta are still attach to uterus after delivery and cause the open blood vessels on the uterus to continue to bleed

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156
Q

Causes of postpartum hemorrhages

A

1) Placenta accreta

2) Uterine atony

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157
Q

What is placenta accreta

A

Abnormally adherent placenta

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158
Q

The majority of cases of placenta accreta are of what type?

A

Placenta accreta vera - adherence to myometrium without invasion through uterine muscle

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159
Q

Risk factors for placenta accreta

A
  • History of placenta previa

- Previous c section

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160
Q

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

A

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)

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161
Q

Treatment for uterine atony

A
  • Oxytocin
  • Methergine
  • Prostaglandin F2-alpha (Hemabate)
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162
Q

MOA of oxytocin in uterus

A

Stimulates frequency and force of contraction

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163
Q

MOA of oxytocin in mammary glands

A

Stimulates contraction of cells to force milk into large sinuses

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164
Q

MOA of oxytocin in cardiovascular system

A

Causes vasodilation, decreased BP, flushing, reflex tachy, increase in limb blood flow

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165
Q

Postpartum dose of oxytocin

A

20 units in 1000mL LR

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166
Q

Infusion rate of oxytocin

A

20-40mU/minute

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167
Q

Onset of IV oxytocin

A

1 min

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168
Q

Duration of IV oxytocin

A

30 min

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169
Q

Side effects of oxytocin

A
  • Hypotension

- N/V

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170
Q

MOA of methergine

A

Acts directly on smooth muscle of uterus via alpha receptors to increase tone, rate, amplitude of uterine contractions

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171
Q

Dosing for methergine

A
  • 0.2 mg IM

- 0.02 mg IV every 5 min

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172
Q

Onset of IV methergine

A

Immediate

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173
Q

Duration of IV methergine

A

45 min

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174
Q

Use methergine cautiously in patients with…

A
  • Pre-eclampsia
  • HTN
  • Asthma
  • Cardiac disease
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175
Q

MOA of prostaglandin F2alpha (hemabate)

A

Stimulates smooth muscle and uterine contractions

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176
Q

Dosage and route of PF2a

A

250mcg IM

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177
Q

Max dose of PF2a

A

2mg

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178
Q

Onset of PF2a

A

Less than 5 min

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179
Q

Duration of PF2a

A

Over an hour

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180
Q

Contraindications for PF2a

A

Asthmatics

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181
Q

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
A

E. All of the above

182
Q

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
A

E. Oxytocin only

183
Q

EBL for uterine inversion

A

Up to 700ml/min

184
Q

Drug management for uterine inversion

A

Give NTG and sevo to relax uterus so OB can manually get it back into shape

185
Q

Which partum hemorrhage causes severe fetal distress?

A

Placenta abruption

186
Q

Which partum hemorrhages have potentially massive intra-op blood loss?

A
  • Placenta previa

- Placenta accreta

187
Q

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
A

E. Placenta previa

188
Q

How is chronic HTN distinguished from pregnancy induced HTN

A

Chronic HTN is diagnosed by systolics over 140 or diastolics over 90s before 20 weeks gestation

189
Q

Pre-pregnancy HTN meds must be changed to a safe antihypertensive such as

190
Q

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
A

D. HYPERTENSIVE DISORDERS OF PREGNANCY

191
Q

Triad of symptoms of pre-eclampsia

A
  1. Hypertension
  2. Proteinuria (over 300mg per day)
  3. Edema after 20 weeks and resolving 48 hours after delivery
192
Q

Risk factors for pre-eclampsia

A

1) Primigravida
2) Primipaternity (first baby with this father)
3) Previous history
4) Obesity
5) Multiple gestations
6) Chronic HTN

193
Q

Signs of severe preeclampsia

A
  1. Systolics over 160 diastolics over 110

2. Proteinuria over 5 grams per day

194
Q

Symptoms of severe preeclampsia

A
  • Headache (due to cerebral edema)
  • Blurred vision
  • Oliguria
  • Pulmonary edema
  • Myocardial dysfunction
  • RUQ pain
  • Hepatic rupture
  • Low platelets
  • HELLP syndrome
195
Q

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”
A

D. WHITE BLOOD COUNT GREATER THAN 15,000

196
Q

What is HELLP syndrome

A

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
Q

What anesthetic method is contraindicated in HELLP syndrome

A

Regional due to low platelets

198
Q

What is eclampsia

A

When seizures occur with preeclampsia

199
Q

Treatment of preeclampsia

A

1) Bedrest
2) Sedation
3) Antihypertensives
4) Magnesium sulfate

200
Q

Dose of labetolol for preeclampsia

201
Q

Dose of hydralazing for preeclampsia

202
Q

Dose of methyldopa for preeclampsia

A

250-500mg PO

203
Q

MOA of magnesium sulfate to treat preeclampsia

A
  • Treats hyperreflexia and prevents seizure by reducing CNS irritability
  • Directly vasodilates smooth muscle of arterioles and uterus
204
Q

Administration of magnesium sulfate can affect the action of what other drugs

A
  • Potentiates NMBs

- Potentiates sedative effects of opioids

205
Q

Dose of magnesium sulfate to treat preeclampsia

A

4g loading dose IV, then 1-3g/hour

206
Q

Therapeutic plasma levels of magnesium sulfate

A

4-6mEq/L (normal is 1.5-2)

207
Q

Serum magnesium levels over 5-10mEq/L can cause

A

Prolonged PQ interval, wide QRS

208
Q

Serum magnesium levels over 10mEq can cause

A
  • Skeletal muscle weakness
  • Loss of deep tendon reflexes
  • Resp depression
209
Q

Serum magnesium levels over 15mEq can cause

A
  • SA/AV block

- Resp paralysis

210
Q

Serum magnesium level that can cause cardiac arrest

211
Q

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

A

C. EXCESSIVE SERUM MAGNESIUM LEVELS CAUSE WIDENING OF THE QRS COMPLEX

212
Q

Antidote for magnesium toxicity

213
Q

Doses of nitroprusside that increase risk of cyanide toxicity to fetus

A

Over 10mcg/kg/min

214
Q

What antihypertensives should not be used during pregnancy?

A
  1. Esmolol (adverse fetal effects)

2. CCBs (tocolytic action, potentiates Mg induced circulatory depression)

215
Q

Anesthetic management of HTN in pre-eclamptic patients

A
  • A-line
  • Labetalol
  • Hydralazine
  • NTG
  • SNP
216
Q

Symptoms of magnesium toxicity

A
  • Oversedation
  • Loss of reflexes
  • Dropping sats
217
Q

Hypovolemia should be corrected with no more than ____ml crystalloid in preeclamptic patients

218
Q

We should tolerate only a __% drop in BP in preeclamptic patients

219
Q

Considerations for general anesthesia for a preeclamptic patient

A
  • Edematous, difficult airways
  • Limit IV fluid
  • Reduce dose of NDNMBs if patient is on magnesium
  • A-line if severe
220
Q

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
A

D. LABETOLOL

221
Q

Is pregnancy tolerated better by regurgitant or stenotic valves

A

Regurgitant valves

222
Q

Which lesions can tolerate epidurals - regurgitant or stenotic valves?

A

Regurgitant valves

223
Q

Most common clinically significant valvular disease in pregnant women

A

Rheumatic fever mitral stenosis

224
Q

Independent predictors of adverse cardiac events in pregnancy

A

1) Small mitral valve area
2) NYHA functional class 3 or higher
3) Ejection fraction less than 40%
4) Prior cardiac events

225
Q

Things to avoid when managing pt with mitral stenosis

A
  • Tachycardia
  • A-fib
  • Increased blood volume
226
Q

Things to avoid when managing pt with aortic stenosis

A
  • Decreased SVR
  • Brady/tachycardia
  • Hypovolemia
227
Q

Common left to right shunts

A

1) VSD
2) ASD
3) PDA

228
Q

Things to avoid in patients with left to right shunts

A
  • XS fluids
  • Trendelenberg
  • Increased SVR
  • Increased blood volume
229
Q

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
A

B. LOWERS SYSTEMIC VASCULAR RESISTENCE

230
Q

Risk factors for gestational diabetes

A
  • AMA
  • Obesity
  • Family history of DM
  • History of stillbirth, neonate death, or fetal malformation
231
Q

Effects of gestational diabetes on the mother

A
  • PIH
  • Polyhydramnios
  • Increased incidence of C section
232
Q

Chronic effects on the fetus from gestational diabetes

A
  • Macrosomia

- Structural malformations

233
Q

Acute effects on the fetus from gestational diabetes

A
  • Intrauterine/neonatal death
  • Neonatal respiratory distress syndrome
  • Neonatal hypoglycemia
234
Q

Most common fetal structural malformation associated with gestational diabetes

235
Q

Anesthetic management for patient with gestational diabetes

A
  • More frequent BP monitoring
  • More vigorous IV hydration (non dextrose-containing)
  • Reglan 10mg IV pre-op
  • Strict glycemic control, glucose under 100
236
Q

Pregnant women have a tendency toward which acid/base disorder

A

Respiratory alkalosis

237
Q

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
A

E. Propofol - good for RSI, rapid

238
Q

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
A

D. MATERNAL SMOKING

239
Q

Why can reversal of NMB with glyco & neostigmine cause fetal bradycardia

A

Glyco doesn’t cross placenta

240
Q

Do muscle relaxants cross placenta?

241
Q

Do inhalation agents cross placenta?

A

Yes - keep below 1 MAC

242
Q

Do induction agents (propofol, ketamine, benzos) cross placenta?

243
Q

Do opioids cross placenta?

244
Q

Which opioid should you NOT use in pregnant patients

A

Meperidine - seizures

245
Q

Which beta blocker is contraindicated in pregnant patients

A

Esmolol - crosses placenta and causes fetal bradycardia

246
Q

Local anesthetic that is bad for pregnant patients

A

Mepivacaine

247
Q

Which local anesthetics poorly diffuse across placenta

A

Highly protein bound - ropivacaine, bupivacaine

248
Q

Which anticholinergic does not cross placenta

249
Q

Recommended vasopressor for maternal hypotension

A

Phenylephrine bc ephedrine accumulates in placenta pretty rapidly

250
Q

Which anticholinergic should be used with neostigmine to reverse NMBs

A

Atropine - but caution its short half life compared to neostigmine

251
Q

Early decelerations in fetal heart rate is caused by

A

Fetal head compression

252
Q

Most commonly encountered fetal heart rate patterns during labor

A

Variable decelerations - caused by compression of umbilical cord

253
Q

Methods to control bleeding during intraop aneurysm rupture

A

Reversal of anticoagulation followed by rapid delivery of coils to seal the bleed

254
Q

Methods to control ICP during intraop aneurysm rupture

A
  • Hyperventilation
  • Hypertonic saline or mannitol
  • Propofol
255
Q

Medical management of vasospasm after subarachnoid hemorrhage

A
  • Nimodipine

- Triple H therapy - HTN, hemodilution, hypervolemia

256
Q

Key anesthetic considerations for neuroradiology procedures

A
  • Patients need to be still
  • BP tightly controlled, frequent use to vasopressors or vasodilators
  • A line
257
Q

Patient contraindications for MRI

A

Patients with…

  • Pacemakers
  • SBSs/DBSs
  • Aneurysm clips
  • Stents
  • Prosthetic valves
  • Prosthetic joints
258
Q

What is more common intraoperatively in pediatric patients - hypo or hyperthermia?

A

Hypothermia

259
Q

What predisposes pediatric patients to hypothermia during surgery

A
  • Low body fat
  • Thin skin
  • Increased BSA:mass ratio, big heads lose heat more quickly
  • Inability to shiver (neonates)
260
Q

What is the typical pattern of hypothermia of pediatric patients under anesthesia?

A

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
Q

What percentage of children present with 1 or more respiratory complications in the PACU?

262
Q

Anatomical differences of the pediatric airway

A
  • Large head, tongue, tonsils, adenoids
  • Anterior and cephalad larynx
  • Long, floppy, omega shaped epiglottis
263
Q

Narrowest point of the pediatric airway

A

Cricoid ring

264
Q

Vertebral level of pediatric vocal cords

265
Q

Calculation for ETT diameter for children age 1 or greater

266
Q

Calculation for ETT depth for children

A

12 + age/2

267
Q

Cons of microcuffed ETTs

A

Smaller size increases airway resistance and work of breathing

268
Q

Cons of uncuffed ETT

A
  • Leak of agent into environment
  • Require flows greater than 2L
  • Higher risk for aspiration
269
Q

1mm of edema decreases area of the trachea by…

270
Q

When are cuffed ETTs preferable?

A
  • High aspiration risk (bowel obstruction)
  • Low lung compliance (ARDS, pneumoperitoneum, CABG)
  • Precise control of ventilation and pCO2 (increased ICP, single ventricle)
271
Q

Risk factors for postintubation croup

A
  • Large ETT
  • Change in patient position intraop
  • Multiple intubation attempts
  • Traumatic intubation
  • Patients under 4
  • Surgery over an hour
272
Q

Treatment for post op croup

A
  • Humidified air
  • Nebulizer treatment
  • Steroids
273
Q

Pathogenesis of laryngotracheal stenosis

A

Ischemic injury caused by lateral wall pressure that leads to edema, necrosis, and mucosa ulceration

274
Q

Why do pediatric patients have less efficient ventilation

A

They have fewer type 1 muscle fibers which causes weak intercostals and diaphragmatic muscles

275
Q

Characteristics of alveoli in pediatric patients

A

Small, immature, and stiff which causes low lung compliance

276
Q

How is chest compliance in pediatric patients

A

Increased due to pliable, cartilaginous ribs

277
Q

O2 consumption in pediatric patients compared to adults

A

Pediatric patients have doubled O2 consumption - 6ml/kg/min

278
Q

FRC of pediatric patients

A

28-30cc/kg

279
Q

Does hypercarbia stimulate ventilation in the term newborn?

A

Yes because their chemoreceptors are developed

280
Q

How soon after birth does hypoxemia induce sustained hyperventilation?

A

By 3 weeks after birth, before then hypoxemia will cause a transient increase in ventilation following by sustained depression

281
Q

How does the slope of the CO2 response curve change with gestational age?

282
Q

Older children and adults are stimulated to breath with a PaO2 under

283
Q

Why is it important to ask about a child’s recent URIs during the pre-op exam?

A

Recent URIs predisposes the child to coughing, laryngospasm, and desaturations

284
Q

What illnesses are normally indicated by a productive cough?

A

Active bronchitis or pneumonia

285
Q

What can be indicated by repeated pneumonia infections??

A
  • GERD

- Immune suppression

286
Q

Signs of impending respiratory failure

A
  • Increased work of breathing
  • Tachypnea/tachycardia
  • Nasal flaring
  • Grunting
  • Wheezing
  • Stridor
  • Use of accessory muscles
  • Diaphoresis
287
Q

How is the need for high O2 consumption in pediatric patients met?

A

Increased respiratory rate

288
Q

How is the myocardium of pediatric patients compared to adults

A
  • Fewer organized myocytes
  • Less contractile tissue
  • Less compliant ventricles
289
Q

What are children dependent on for their cardiac output?

A

Heart rate because their stroke volume is fixed due to less compliant ventricles

290
Q

When does the conversion from fetal to adult circulation occur?

A

First few weeks of life

291
Q

How does the baby’s circulation start to change when they take their first breaths?

A

Start conversion to adult circulation…PVR drops, SVR increases which begins the closure of the PDA and foramen ovale

292
Q

When does the full closure of the PDA and foramen ovale occur in babies?

A

3 months-1 year

293
Q

How is a patent foramen ovale diagnosed?

294
Q

Neonatal hemoglobin

295
Q

Hemoglobin of a 3 month infant

A

11-12g/dL (relative anemia)

296
Q

When does the infant begin the conversion to adult hemoglobin?

297
Q

When does a baby’s hemoglobin levels reach adult levels?

A

6-9 months

298
Q

Blood volume for a preemie

A

90-100ml/kg

299
Q

Blood volume for a full-term neonate

A

80-90ml/kg

300
Q

Blood volume for a 12 month infant

A

75-80ml/kg

301
Q

Pediatric dose of atropine

A

0.01-0.02mg/kg IV

302
Q

Minimum PALS dose of atropine

A

0.1mg - below that you can see paradoxical bradycardia

303
Q

Pediatric dose of IV sux

304
Q

Pediatric dose of IM sux

305
Q

Pediatric dose of PO versed

306
Q

Pediatric dose of IV versed

307
Q

Max dose of PO versed for pediatrics

308
Q

Pediatric dose of rocuronium

A

0.6-1.2mg/kg

309
Q

Pediatric dose of fentanyl

310
Q

Pediatric dose of zofran

311
Q

Pediatric dose of ancef

A

25-50mg/kg

312
Q

Infants sometimes require up to 3mg/kg of succinylcholine…why?

A

They have a higher volume of distribution

313
Q

Fasting guidelines for clear liquids

314
Q

Fasting guidelines for breast milk

315
Q

Fasting guidelines for milk/formula/light meal

316
Q

Fasting guidelines for fatty meal

317
Q

Metabolic rate of infants

A

100cal/kg/day

318
Q

Gas combo commonly used for inhalational induction of pediatric patients

A

70/30 N2O/O2 with sevo all the way up

319
Q

Why should you be more careful using fentanyl in children

A

More susceptible to post op apnea

320
Q

How do MAC requirements change as you move from preemies to neonates to infants

A

Infants have the highest, preemies have the lowest

321
Q

What is the rule of thumb for who to give caudal blocks to? Why?

A

Kids younger than 7 OE less than 30 because the fusion of the sacrum is not yet complete

322
Q

How are caudal blocks done?

A

Form of epidural that is placed as a single shot injection into the sacral hiatus after induction

323
Q

Dose and type of local used in caudal blocks for circumcision

A

0.5cc/kg 0.25% marcaine

324
Q

Dose and type of local used in caudal blocks for inguinal hernies

A

0.75cc/kg 0.25% marcaine

325
Q

Surgeries that commonly have deep extubations for children

A
  • Cath lab

- Eye cases

326
Q

Criteria for deep extubation

A
  • 100% O2
  • At least 1.5MAC
  • Breathing spontaneously
  • Suctioned
  • Oral airway
  • No breath holding
327
Q

Steps to take in case of suspected laryngospasm

A
  • Chin lift
  • Jaw thrust
  • Positive pressure
  • Sux
328
Q

Patients at risk for respiratory events in PACU

A
  • Active respiratory infection
  • History of reactive airway disease
  • Children 0-9 y/o
  • Asthma
329
Q

At what point under anesthesia’s care do most cardiac arrests occur in children?

330
Q

Common mechanisms of cardiac arrest in children

A
  • Bradycardia
  • Airway obstruction
  • Medication related
331
Q

3 Predictors of anesthesia-related cardiac arrest

A

1) ASA 3-5
2) Emergency
3) Younger age

332
Q

Why do we not put young preemie babies on a high FiO2?

A

They are predisposed to retinopathy until 44 weeks

333
Q

ETT sizing for down syndrome children

A

Downsize tube by 0.5mm

334
Q

At what point during gestation is extrauterine life possible?

335
Q

When do lungs develop in the fetus?

A

Sufficient pulmonary surfactant isn’t until 35 weeks gestation

336
Q

Biggest concern for the airway of down syndrome children

A

Very prone to atlanto-occipital dislocation due to unstable c-spine

337
Q

Intra-op plan for children with sickle cell

A
  • Keep them warm
  • Keep them well hydrated
  • Treat pain aggressively
  • Be prepared to transfuse
338
Q

Characteristics of pediatric trachea

A

Small and compliant, cartilages are not well calcified. Prone to laryngomalacia

339
Q

P50 of neonatal hemoglobin

340
Q

When should elective surgery be cancelled in a patient with a URI?

A
  • Purulent rhinitis
  • Fever over 38.3C
  • Elevated WBC with bands
  • Infiltrate by CXR
341
Q

Former preterm infants are at risk for what lung problems?

A
  • Pulmonary HTN

- Chronic lung disease

342
Q

What medications are former preterm infants commonly on? Should they take them morning of surgery?

A
  • Lasix to keep lungs dry (hold morning of)

- Digoxin for right heart failure (take morning of)

343
Q

Characteristics of bronchopulmonary dysplasia (BPD)

A
  • Increased airway resistance
  • Poor lung compliance
  • VQ mismatch
  • Hypoxemia
  • Tachpnea
  • Chronic wheezing
344
Q

Former preterm infants should be monitored for post op apnea if they are under __ weeks post conceptual age (PCA)

345
Q

Pre-op considerations if child has a murmur

A
  • Get preop ECHO if murmur is Gr III or greater

- Determine need for SBE prophylaxis

346
Q

Pre-op considerations for patient with sickle cell disease

A
  • Baseline H/H
  • No electrophoresis
  • Tranfuse to Hct of 30% with PRBCs
  • Have blood available in OR
347
Q

Pediatric dose for nasal versed

348
Q

Pediatric dose for oral ketamine

349
Q

Pediatric dose for transmucosal fentanyl

A

10-15mcg/kg

350
Q

Pediatric dose for rectal methohexital

351
Q

What are the pre-op lab protocols for healthy children?

A

No routine labs (with some exception in ENT cases)

352
Q

Pediatric dose for PO acetaminophen

353
Q

Pediatric dose for PR acetaminophen

354
Q

Pediatric dose for PO NSAIDS

355
Q

Pediatric dose for IM ketorolac

356
Q

Pediatric dose for IV ketorolac

357
Q

Duration of caudal block

358
Q

Minimum discharge criteria for pediatric ambulatory surgery

A
  • Stable vital signs (within 20% baseline)
  • No resp distress
  • Age appropriate ambulation and LOC
  • No n/v
  • In tact pharyngal reflexes
359
Q

Max dose of zofran for peds patients

360
Q

Pediatric dose for IV droperidol for PONV

A

50-75mcg/kg

361
Q

Pediatric dose for IV metoclopramide for PONV

362
Q

Pediatric dose for IV or PR promethazine for PONV

363
Q

Pediatric dose for PR prochlorperazine for PONV

364
Q

Potential neuroprotectants from toxicity of anesthetic agents

A
  • Lithium
  • Dexmedetomidine
  • tPA, plasma, erythropoietin
365
Q

GFR of neonate compared to adult

A

Neonates have 15-30% of the adult GFR

366
Q

Renal/hepatic metabolism considerations for neonates

A
  • Hypoglycemia and hyperglycemia can occur very easily

- Calcium metabolism is easily disturbed and citrate binding can cause pressor resistant hypotension

367
Q

What are omphaloceles/gastroschisis

A

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
Q

Characteristics of omphalocele

A
  • Gut fails to migrate from yolk sac into abdomen
  • More common than gastroschisis
  • More common in males
  • Defect at base of umbilicus
369
Q

Characteristics of gastroschisis

A
  • 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
Q

Which fetal bowel abnormality still has a functional bowel

A

Omphalocele

371
Q

Which fetal bowel abnormality is associated with other congenital abnormalities thus has higher mortality

A

Omphalocele

372
Q

Which fetal bowel abnormality has organs that are inflamed and edematous due to exposure to amniotic fluid

A

Gastroschisis

373
Q

Preop considerations for patients with Omphalocele/Gastroschisis

A
  • Heat and fluid loss from large exposed area
  • Volume depleted
  • Check pulmonary status (could have RDS from prematurity)
  • Check renal function
374
Q

Patients with Omphalocele/Gastroschisis are at risk for what electrolyte imbalances

A
  • Hypoglycemia

- Hypocalcemia

375
Q

Standard monitors for patients with Omphalocele/Gastroschisis

A
  • Standard ASA
  • A line
  • Urinary catheter
  • Intra-abdominal pressure monitoring
  • +/- CVP
376
Q

Anesthetic induction for Omphalocele/Gastroschisis

A
  • Awake intubation if hypovolemic

- RSI after IV atropine and O2

377
Q

Where do you want ETT leak for patients with Omphalocele/Gastroschisis

A

30-40cmh2o

378
Q

Anesthetic maintenance for patients with Omphalocele/Gastroschisis

A
  • O2/air/volatile
  • Max muscle relaxation
  • Opioid 5-20mcg/kg fentanyl
379
Q

Intraop management for patients with Omphalocele/Gastroschisis

A
  • 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
Q

Fluid maintenance for patients with Omphalocele/Gastroschisis

A

D10 25% NC 10-15cc/kg/hr

381
Q

Postop management for patients with Omphalocele/Gastroschisis

A
  • 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
Q

What is the most common cause of neonatal GI obstruction

A

Hirschsprung’s disease

383
Q

Hirschsprung’s disease

A

Absence of ganglion cells needed to allow relaxation of internal sphincter, presents as failure to pass meconium within first 24 hours of life

384
Q

Anesthetic induction considerations for pediatric patients with transesophageal fistula (TEF)

A
  • Head up position (minimize aspiration)
  • NG in esophagus with continuous suction
  • Warm room
  • T&C units
  • Good IV access
385
Q

Induction plan for TEF

A
  • Atropine 10-20mcg/kg IV

- Awake vs RSI

386
Q

Appropriate ETT position for patients with TEF

A

Past fistula but above carina

387
Q

Monitors for patients with TEF

A
  • Standard ASA
  • A line
  • Pre and post ductal pulse oximeters
  • Axillary precordial stethoscope
388
Q

Position for TEF procedure

A

Lateral decubitus

389
Q

Postop management of TEF

A
  • Extubation preferable to minimize stress/compression

- Humidified O2

390
Q

Cardiovascular mangement for infants with Necrotizing Enterocolitis (NEC)

A
  • Urgent fluid/blood resuscitation at 150cc/kg in NICU
  • Inotropes
  • Infants usually acidotic, in shock, and have assc. CHF
391
Q

Metabolic conditions of NEC

A
  • Severe acidosis
  • Hypoglycemia
  • Hypocalcemia
392
Q

Calculation for bicarb deficit in peds

A

Base deficit x weight x 0.3

393
Q

How much bicarb should be given to NEC patients in preop

A

Half the calculated deficit - give slowly

394
Q

EBL for NEC procedure

A

10-100cc/kg

395
Q

Monitors for NEC

A
  • Standard ASA
  • A line
  • Urinary catheter
  • +/- CVP
396
Q

Anesthetic plan for NEC

A
  • Ketamine
  • O2/air
  • Opioids
  • Muscle relaxation
  • Sat 94-95%
397
Q

Postop plan for NEC

A
  • Maintain PPV
  • Continue opioids and muscle relaxation
  • Transport with extra volume, airway equipment, full monitors, drugs
398
Q

Preop management for congenital diaphragmatic hernia (CDH)

A
  • Stabilize or ECMO
  • Correct acidosis
  • Treat pulmonary HTN
  • Check PT/PTT/platelets
399
Q

Monitors for CDH

A
  • Standard ASA
  • A line
  • Pre/postductal pulse oximters
  • Urinary catheters
  • Precordial stethoscope on side opposite defect
400
Q

Induction plan for CDH

A

Awake intubation

401
Q

Ventilation plan for CDH

A
  • IMV 60/min
  • PIP under 30cmh2o
  • PaCo2 25-30
  • pH over 7.5
  • PaO2 under 80
  • may need pressure limited ventilator
402
Q

Fluid management for CDH procedure

A
  • D5 1/4 NS 4-6cc/kg/hour

- 5% albumin 5-10cc/kg

403
Q

Postop management of CDH

A
  • Maintain PPV and respiratory alkalosis
  • Minimize suctioning
  • Provide nutrition
404
Q

Indications for pediatric ECMO

A
  • Reversible respiratory failure
  • Meconium aspiration
  • CDH
  • Drowning
  • Infection
  • Asthma
405
Q

Entry criteria for ECMO

A
  • Over 34 weeks gestation
  • Over 2kg
  • 80% predicted mortality
406
Q

Exclusion criteria for ECMO

A
  • Greater than grade 2 intraventricular hemorrhage

- Other life threatening anomalies

407
Q

What are Myelodysplasias

A

Abnormal fusion of neural groove leaving some portion of brain or cord exposed

408
Q

Preop management of Myelodysplasias

A
  • Check neurologic deficits
  • Check volume status
  • Plan A/W management
  • Warm room
409
Q

Induction plan for Myelodysplasias

A
  • Awake intubation for nasal encephaloceles

- Inhalation or IV

410
Q

Myelodysplasia patients are extubated in what position

411
Q

What is a Cystic Hygroma

A

Large lymphatic malformations that can extend to mediastinum

412
Q

Morbidity assc. with cystic hygromas

A
  • Airway compromise
  • Infection
  • Bleeding
413
Q

Labs needed for cystic hygroma surgery

A
  • Hct
  • Glucose
  • Calcium
  • T&C units
414
Q

IV access considerations for cystic hygroma

A

Consider IVs in lower extremities

415
Q

Induction plan for cystic hygroma

A
  • Volatile + 100% O2
  • Atropine before DL
  • Maintain spontaneous ventilation
416
Q

Postop plan for cystic hygroma

A
  • Take to ICU for airway monitoring, probably wont extubate due to edema
  • Monitor for RLN injury, bleeding, edema
417
Q

Intubation plan for neonates with encephalocoele

A

Awake intubation for nasal encephalocele, otherwise IV or inhalational

418
Q

How do vital signs change during the progression of neonates to children

A
  • RR decreases
  • Heart rate decreases
  • BP increases
419
Q

Indications for TIPS

A
  • Portal vein HTN

- ESLD

420
Q

Which neonatal surgical emergencies require awake intubations

A
  • Nasal encephaloceles
  • Omphalocele/gastroschisis if hypovolemic
  • Congenital diaphragmatic hernia
  • Tracheoesophageal fistula
421
Q

Pediatric ETT depth of insertion confirmation

A
  • Bilateral breath sounds

- Pressure leak test

422
Q

Measuring pre- vs postductal circulation

A
  • 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
Q

Blood volume of a full term neonate

A

80-90ml/kg

424
Q

Benefits of pediatric premedication

A
  • Calms child so they accept mask induction
  • Less anxiety for child and parents when separating
  • Diminishes post op behavioral changes
425
Q

What is nonshivering thermogenesis

A

Brown fat metabolism - norepi stimulates breakdown of brown fat and glycerol that results in heat and increases O2 production

426
Q

Treatment for pelvic relaxation

A
  • Bladder training and biofeedback
  • Anticholinergics
  • Beta agonists
  • Dopamine agonists
  • Antidepressants
  • Kegal exercises
427
Q

Mortality in gynecologic cancers

428
Q

Blood volume during pregnancy

A

Increases 40% from baseline

429
Q

Normal BP for neonate

430
Q

Normal BP for 1 year old

431
Q

Normal BP for 3 year old

432
Q

Normal BP for 12 year old

433
Q

Most common complication of 2nd trimester D&E

A

Gestational diabetes

434
Q

Blood loss during L&D

A
  • Vaginal delivery=400-500ml

- C section=800-1000ml

435
Q

Maternal cardiac output distribution

A

700ml/min to fetus

436
Q

Determinants of uterine blood flow

A

Blood pressure

437
Q

What is not a contraindication to neuraxial anesthesia for the Ob patient?

A

Hyperglycemia

438
Q

MgSO4 site of action

A
  • Calcium channel blocker – vasodilates smooth muscles in arterioles and uterus
  • NMDA antagonist – stops seizures
439
Q

Cause of early decelerations in fetal heart rate

A

Head compression

440
Q

Cause of late decelerations in fetal heart rate

A

Uteroplacental insufficiency – suggestive of asphyxia

441
Q

Cause of variable decelerations in fetal heart rate

A

Umbilical cord compression

442
Q

Causes of antepartum hemorrhage

A

1) Placenta previa

2) Placental abruption

443
Q

Changes in cardiovascular measurements during pregnancy

A
  • HR increases 20-25%
  • SV increases 25%
  • CO increases 50%
  • SVR decreases
444
Q

Signs of amniotic fluid embolism

A

Classic triad is acute hypoxemia, severe hypotension, coagulopathy

445
Q

Methergine Uses

A

Uterine smooth muscle constrictor used to stop excessive post-delivery bleeding

446
Q

Pregnancy - timeline of cardiac output increases

A
  • During pregnancy it increases by 50%

- Immediately after pregnancy it increases as much as 80%

447
Q

P50 of maternal hemoglobin

448
Q

PaCO2 normal values in 3rd trimester

449
Q

Symptoms caused by cardiac tamponade

A
  • Distant heart sounds
  • JVD
  • Hypotension
450
Q

Positioning for ERCP

A

Prone with patient’s head to their right

451
Q

Incidence of gastroschisis

Anesthesia Practice (9 decks)

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