Complications In Obstetric Anesthesia Flashcards
Most common cause of postpartum maternal palsy (intrinsic obstetric paralysis
Cephalopelvic disproportion which results in lumbosacral trunk compression as it crosses the pelvic brim by the baby’s head
intrinsic obstetric paralysis I swore common in its who had anesthesia: true or false
False. They were more frequent in pts who had no anesthetic and were the same for epidrual and GA
What causes 75% of preggos to have a backache (new onset for 60%)
- increased lumbar lordosis to counterbalance the growing uterus
- increased laxity of cacrococcygeal, sacroiliac, and pubic joints
- soft tissue trauma (common but self limited)
complications of neuraxial blocks
- Nerve injury
- PDPH
- High or total spinal anesthesia
5 types of nerve injury caused by neuraxial blocks
- epidural hematoma
- epidural abscess
- chemical nerve injury
- needle trauma
- positioning injury
2 causes of epidural hematoma and a way to prevent it
- block placement
- Cath removal
only insert or remove epidural when coag fx is normal
describe a pt who would be safe for neuraxial blockade
- no hx of bleeding problems
- no s/s PIH (preg induced HTN)
- not on anticoags
Paramaters for safe neuraxial blockade in pt with PIH
- plt ct >100K
- normal PT, PTT (required)
- Plt ct insta rapidly falling (could be HELLP syndrome; recheck if last check was >6-8 hrs ago)
Lovenox
- avoid neuraxial block for _____ if therapeutic anticoagulated
- avoid neuraxial block for _____ if prophylactic anti coagulated
- Remove catheter at least _____ hrs after last dose4.
- do not administer LMWH until ______ hr after block is placed or Cath is removed
- avoid concurrent ___ or ___
- 24 h
- 12 h
- 12 h
- 2-4 h
- NSAIDS or anticoagulants
S/S epidural hematoma
- bilat leg weakness
- incontenence
- absent rectal sphincter tone
- back pain
what actions should be taken if epidural hematoma is suspected?
- STAT CT or MRI
- surgical decompression w/in 6 hrs for full neurological recovery to occur
Bottles of 10% iodine can become colonized w bacteria after ______
a single use
___% of lumbar epidural catheters are colonized, mostly by ____ bacteria after _____ days w/o signs of local infection
25%
Gram +
1-5 days
how long does it take for signs of epidural infection to appear? what are the most common signs?
4-10 days
pain and loss of fx
tx for epidural abscess; how long do you have to tx it before permanent damage?
ABX and laminectomy
6-12 hrs
How does epidural abscess usually present?
- Severe back pain (worse w flexion; sometimes radiation)
- exquisite local tenderness
- fever, malaise, meningitis-like HA w neck stiffness
- lab changes (inc. WBC and ESR, positive BC)
- progression over hrs to days to neuro deficit or osteomyelitis
What makes the epidural space very resistant to toxicity?
- it is very vascular
- the membrane b/t it and the subarachnoid space must be intact
What are the s/s of transient neurological symptoms (TNS)?
pain and dysphasia in butt, legs, or calves that can follow SAB (subarachnoid block); resolves w/in 72 hrs
Most common cause of TNS (transient neurological symptoms)
- Lidocaine spinals (high concentration in high doses)
- lithotomy position
Where is the conus of the spinal cord?
T12-L3
T/F: Hitting the cord w a small needle causes significant pain and paresthesias but if needle immediately w/d, usually no permanent sequalae.
True, but if you inject into the cord, that is a different story.
T/F: regional blocks are best done on sleeping pts
FALSE
2 common compression injuries in pregnancy and their causes
- common peroneal nerve - lithotomy stirrups
2. femoral or obturator nerves - lithotomy position
T/F: Nerve compression injuries may range from transient ischemic injury to axonal crush. recovery could be in 2-6 days if mild or 2-3 yrs to permanent if severe.
True
If your pregnant has post partum foot drop, what injuries would you suspect?
either common peroneal from stirrups or brow compression of lumbosacral trunk (it is probably the CPN)
How to differentiate b/t femoral and obturator neuropathy
- femoral - difficulty climbing stairs
- obturator - decreased sensation over upper inner thing and weak hip adduction (weird patches of numbness)
Common presentation and onset of PDPH
- throbbing, postural, variable distribution HA
- onset: 12-48 h after dura puncture
T/F: PDPH is typically self limited w a spinal needle, less likely with an epidural, is usually self-limited, but can become chronic.
True
principal determinants of a PDPH
size of dural hole
type of needle used
what types of needles would you use if you want to increase likelihood of PDPH in your pt?
larger gauge and cutting edge needles
Normal CSF volume is _____
How much CSF is made/day?
150 cc
450 cc/day
Acute loss of _____ cc of CSF will produce HA symptoms caused by ______ when pt assumes an upright posture.
20 cc
sagging of intracranial contents and stretching of the pain sensitive tissues
PDPH risk factors
- young age
- big needle
- cutting-edge Quincke spinal needle
- cephalic or caudal orientation of Quincke needle
- hx of PDPH or migraines
Risk factors for dural puncture w epidural needle
- Me - I have no experience
- Air LOR technique (saline is less risk)
- fatigue or haste (night shift)
