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Class 2 Analgesia & Pharmacology Flashcards

1
Q

Describe the 1st stage pain pathway, and what dermatomes they are associated with.

A
  • Lower uterine from contractions

- T10 - L1

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2
Q

Describe the 2nd stage pain pathway and it’s associated dermatomes.

A
  • Perineal structure via pudenal nerve

- S2-S4 (not covered by epidural)

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3
Q

Opioids that cross the placenta can do what 2 things to the fetus?

A
  • Loss of beat to beat variability

- Decreased movement

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4
Q

Name the 4 PCA advantages

A
  • Satisfaction scores
  • Less neonatal depression
  • Less nausea
  • Less maternal respiratory depression
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5
Q

Why is morphine not used?

A

-increased risk of respiratory depression r/t Immature BBB in baby

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6
Q

Demerol (meperidine) concerns

A
  • Nausea and vomiting
  • Baby respiratory depression unlikely if given < 1hr prior to delivery
  • contraindicated with seizure / or renal failure (metabolite)
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7
Q

Fentanyl concerns

A
  • Rapid placenta transfer

- resp depression longer than analgesia benefits

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8
Q

Nubain concerns

A
  • Ceiling effect on respiratory depression
  • Dysphoria
  • treats opioid induced puritis
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9
Q

Stadol concerns

A
  • Sedation
  • Ceiling effect on resp depression
  • better analgesic profile than fentanyl
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10
Q

Volatile agent concerns

A
  • Rarely used
  • pulmonary aspiration risk
  • decreased uterine tone
  • Supplement to nerve block
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11
Q

When is a pudenal block used, and on what patients?

A
  • 2nd stage of labor

- pts with contraindication of neuraxial block

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12
Q

Risk of Pudenal block

A
  • Fetal injury
  • Infection
  • Hematoma
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13
Q

when is a paracervical block used? What pain does it help with?

A
  • When epidural cannot be achieved

- 1st stage labor

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14
Q

What are the complications of paracervical block?

A
  • Uterine artery injection,
  • fetal LA toxicity,
  • nerve injury,
  • hematoma
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15
Q

Ester local anesthetics.

A
  • PABA
  • Metabolized by plasma cholinesterase
  • PABA metabolite is an allergen
  • No previous “I”
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16
Q

Amide local anesthetic tidbits

A
  • Metabolized by liver
  • No PABA, allergic reactions rare
  • 2 “i”s
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17
Q

Local anesthetics site of action?

A

-Neuronal cell membrane sodium channel

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18
Q

What determines the speed of Local anesthetic onset?

A

-pKa

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19
Q

To have a faster onset you would want pKa closer or farther away from physiological pH?

A

Closer

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20
Q

How can you artificially raise pH, to be closer to pKa?

A

-Add bicarb

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21
Q

Once across the membrane what form of drug is responsible for receptor binding and blockade?

A

-Polar form

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22
Q

What dictates the onset, quality and duration of a Local Anesthetic?

A

-Total dose

23
Q

increasing dose =

A

faster onset and longer duration

24
Q

How do vasoconstrictors effect LA?

A
  • prevent absorption

- More available for blockade

25
How does temperature effect LA?
-Warm LA reduces onset time
26
How does pregnancy effect LA?
- Smaller amounts are required | - Faster onset
27
Small and poorly myelinated nerves, like type ____ fibers are ______ ______ susceptible to blockade.
- C | - More rapidly
28
Large, myelinated nerves like type ____ fibers require ______ concentrations of LA for blockade.
- A | - Higher
29
Local Anesthetic used for labor epidural.
- Bupivicaine - Ropivacaine - Lidocaine
30
Local Anesthetic used for operative epidural.
- Lidocaine | - 2-chloroprocaine
31
Local anesthetics used for OB spinal anesthesia?
- Tetracaine | - Bupivacaine
32
Lidocaine concerns
- Not for continuous infusion - Test epidural catheter function - Motor block - activate epidural for C-section - Short duration
33
2-chloroprocaine concerns
- only ester used in epidural space - Rapid onset / short duration - Large motor block - low risk of toxicity
34
2-chloroprocaine will interfere with the analgesic effects of what med?
-Epidural fentanyl
35
Bupivacaine concerns (used at Hamot)
- Long duration | - Less motor block (can still feel contractions and push)
36
What happens if a large does of bupivicaine is given IV?
- CV collapse | - Refractory V-tach/V-fib
37
Benefits of levobupivicaine?
-less cardiotoxic
38
Ropivicaine benefit and problem.
- Less cardio toxic | - 25% less potent
39
What is the best lumbar level to cover in OB? Where should catheter be placed to achieve that level?
- T10 - S4 | - L3 - L4
40
For 95% of OB, the spinal chord ends at? The other 5%?
- L1 | - L2/3
41
What imaginary line passes between the iliac crests?
-Truffiers (about L3/4)
42
Contraindications to neuraxial block?
- Patient refusal - Infection - Intracranial mass - Coagulopathy - Aortic stenosis - Spinal pathology - Hemodynamic instability
43
On average the epidural space is how deep?
4.75 cm
44
How much of the tip should be in the epidural space?
-5 cm
45
What are the differences between spinal and epidurals?
- Spinal is one tissue layer deeper - Drugs given via spinal are 10x more potent - Spinals require smaller needle
46
When is a subarachnoid block used?
- C-sections | - Not enough time for epidural
47
Benefit and problem with combined spinal / epidural
- instant relief | - Cant test epidural catheter
48
Local anesthetic Central nervous system toxicity problems?
- Tinnitus - Metallic taste - Light headedness - Circumoral numbness - Convulsions - LOC - Respiratory arrest
49
Increase in what 2 things lower the seizure threshold?
- PaCO2 | - Acidosis
50
How doe LA toxicity effect the CV system?
- Sodium channel inhibition - Decrease depolarization of purkinjes fiber and ventricle muscle - Decrease action potential - Decrease refractory period - Increased toxicity to bupivicaine and cocaine
51
LA toxicity is treated by what?
-20% intralipid
52
Subdural block is located where?
-Between dura and arachnoid matter
53
A subdural block may involve what?
- Cervical roots - Cranial nerves - Trigeminal block - Horners syndrome

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