Exam 3: Key Terms Flashcards
What are some nonsurgical treatment options for pelvic relaxation?
- Bladder training and biofeedback
- Medical therapy (Anticholinergics, beta agonist, dopamine agonist, antidepressants)
- Kegel exercises
What is the only definitive treatment option for pelvic relaxation and prolapse?
Surgical Treatment
- Anterior vaginal wall repair
- retropubic suspension procedure
- sling procedure
Define endometriosis
Presence of endometrial tissue in extrauterine locations
What is the most common benign tumor in the female genital tract?
Leiomyoma (fibroids)
What are the symptoms of Leiomyomas (fibroids)?
- Bleeding (most common)
- Pain
- Pressure symptoms
What is the most common form of GYN cancer that also has the highest survival rate among American women?
Cervical cancer
-Routine Pap smears make identification of precursor lesions easier
What form of GYN cancer has the highest mortality rate?
Ovarian cancer
Much harder to detect, symptomatic only after extensive metastasis
What is pelvic relaxation/pelvic organ prolapse?
When there is descending or prolapsing into the vaginal wall.
(Urethrocele, cystocele, rectocele)
Where is endometriosis commonly found and what is the widely excepted cause?
Ovaries (60%)
Retrograde menstruation is widely excepted cause
How is diagnosis of endometriosis made and what is the definitive treatment?
Diagnosis under direct visualization (surgery)
Definitive treatment = TAH w/ BSO & removal of adhesions
{TAH w/ BSO = Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy}
Growth potential of fibroids is related to what? And what generally stops their growth?
Growth potential is related to estrogen production
Menopause generally stops it
What does it mean when a fibroid is pedunculated and what effect does it have on the patient?
Pedunculated = on stalk, twists, loses blood supply
Extremely painful
What are the surgical treatment options for fibroids?
Myomectomy = more complications, attempt to preserve fertility
Hysterectomy = Definitive treatment for women who have completed childbearing
What is the most common indication for hysterectomy?
Leiomyomas (fibroids)
What does the depth of penetration of malignant cells tell you about cervical cancer?
Depth of penetration of malignant cells predicts extent of the cancer and likelihood of metastases
How does laparoscopy differ from laparotomy?
Laparoscopy = inspection and manipulation of tissue within abdominal cavity using endoscopic instruments
Laparotomy = inspection and manipulation of tissue via an incision that permits good exposure
What is the difference between a total and radical hysterectomy?
Total = removal of all of uterus Radical = removal of uterus with very wide margins of surrounding tissue
How does pregnancy affect blood volume?
Blood volume increases from
Normal = 60-65 mL/kg
Pregnancy = 90 mL/kg (3rd Trimester)
What are the normal values for PaCO2 in 3rd trimester?
Normal PaCO2 = 40 mmHg
1st/2nd/3rd trimester = 30 mmHg
What effect does pregnancy have on cardiovascular measurements?
CO = +40% SV = +30% HR = +15-30%
SVR = -20% PVR = -30%
What affect does caval compression have on hemodynamics and how is this alleviated?
Decreases cardiac output 25 to 40%
(Hypotension)
Alleviated most often by left uterine displacement
What is Methergine used for?
Stimulates contractions, given after delivery to reduce size/blood loss by making the uterus “clamp down”
What effect does pregnancy have on lung volumes and respiration?
TV = +40% RR = +0-15% MV = +40% VO2 = + 60%
FRC = -20% (desat. faster)
What are the determinants of uterine bloodflow at term gestation?
Uterine bloodflow is PRESSURE DEPENDENT, NOT auto-regulated
From 50mL/min -> 600-700mL/min @ term
(Increase pressure, increase flow)
What is the P50 of maternal hemoglobin? How is this different from fetal or normal hemoglobin?
Maternal = 30 Normal = 27 Fetal = 19
Normal physiological changes during pregnancy effect what systems?
Cardiovascular Respiratory Neurological Renal Hepatic Endocrine Gastrointestinal
When during the course of pregnancy and delivery is cardiac output greatest?
Cardiac output greatest immediately following delivery
What effect does pregnancy have on MAC requirements? Local anesthetics?
Decreases MAC progressively (up to 40%)
Decreases local requirements (up to 33%)
What happens to PT and PTT in pregnant women?
Both shortened by 20%
Describe the stages of labor
Stage 1: water breaks, contractions start, ends with full cervical dilation
Stage 2: fetal descent and delivery
Stage 3: delivery of placenta
What effect does labor have on minute ventilation and oxygen consumption?
MV = 300% increase during intense contractions
VO2 = 60% increase from 3rd trimester values
What are some of the effects of preeclampsia?
HTN Proteinuria Edema Headache Blurred vision RUQ pain Low platelet count HELLP syndrome
When considering 3rd trimester bleeding, what is the difference between placenta previa and placental abruption?
Placenta previa = painless vaginal bleeding
–can localize on ultrasound
Placental Abruption = separation of placenta (most common cause of intrapartum fetal death)
- port wine colored amniotic fluid
- internal bleeding can make it difficult to gauge blood loss
What is a classic test dose for an epidural catheter?
45 mg of 1.5% lidocaine with 1:200,000 epi in 3mL
What is a normal fetal heart rate?
110-160 bpm
With neuraxial anesthesia, what level block is necessary for a C-section?
T4 (nipple level)
What is true of pregnant women and local anesthetics?
More sensitive by up to 33%
- Decreased CSF volume causes enhanced cephalad spread of local
- Higher risk for LAST
Early decelerations in fetal heart rate tracings are often associated with what?
Head compression as fetus moves toward delivery
Variable decelerations in fetal heart rate tracing are often associated with what?
Umbilical cord prolapse
-Umbilical cord comes between baby and opening, cutting off O2
Late decelerations in fetal heart rate tracings are suggestive of what?
Fetal asphyxia following contractions, such that contractions are cutting off fetal blood supply
What is the site of action for magnesium sulfate?
Direct vasodilation action on smooth muscle of arterioles and uterus
Why is it important to measure heart rate decelerations on the fetal heart rate tracing?
Heart rate decelerations are one of the only measurable fetal responses to stress
What type of anesthetic is preferred for a C-section and why?
Neuraxial
-Mortality rate 17x greater with general than with neuraxial anesthesia.
Why is pre-hydration for the parturient receiving a spinal block important?
Helps prevent hypotension
What is the most common indication for C-section?
Arrest of dilation
What is the first sign of hypotension in the parturient?
Nausea and vomiting
What NMB is typically used for induction during a stat C-section?
Succinylcholine
What drug is often used as an adjunct for analgesia in the presence of an inadequate block?
Ketamine
What is the number one cause of maternal mortality worldwide?
Hemorrhage
US = cardiovascular disease
What is the safest and most effective medical intervention for labor pain?
Lumbar epidural
Pain during stage 1 comes from the uterus and cervix. Where are they innervated?
T10-L1
What is the difference in pain during stage 1 and stage 2?
Stage 1 = visceral (intense, but dull. Not localized)
Stage 2 = somatic (sharper, well localized)
What are some of the signs of amniotic fluid embolism?
Triad: 1. Acute hypoxemia 2. Hemodynamic collapse 3. Coagulopathy without obvious cause (DIC)
Others: Tachypnea, cyanosis, CV shock, pulmonary edema, fetal distress, seizures
What are two causes of antepartum hemorrhage?
Placenta previa
Placental abruption
Define premature labor
Labor that occurs between 20 and 37 weeks gestation
What is chorioamnionitis?
Infection of the chorionic and amniotic membrane, may involve the placenta, uterus and umbilical cord
What are the clinical signs of chorioamnionitis?
Fever
Maternal and fetal tachycardia
Uterine tenderness
Foul-smelling amniotic fluid
What is the mortality rate associated with amniotic fluid embolism?
86%
Most diagnosed postmortem
What is the most common cause of intrapartum fetal death?
Placental abruption
What is the most common form of placenta accreta?
Placenta accreta vera
-Adherence to myometrium without invasion of or passage through uterine muscle
What is the major cause of postpartum hemorrhage?
Uterine atony
How is uterine atony treated?
Oxytocin
Methergine
Hemabate
What is HELLP syndrome?
PIH associated with
Hemolysis
Elevated Liver enzymes
Low Platelet count
What type of anesthetic is generally not recommended for patients with HELLP syndrome?
Regional
-Platelet count actively falling
Which drug used to treat hyperreflexia and prevent seizures in eclampsia can potentiate NMBs and sedative effects of opioids?
Magnesium sulfate
What is the therapeutic level of magnesium sulfate and what can happen in excess of this range?
Therapeutic = 4-6 mEq/L
Above Therapeutic Level: ECG changes, muscle weakness, respiratory depression, SA/AV block, cardiac arrest
Which two drugs can you not use for the treatment of PIH?
Esmolol (Bad for baby)
Calcium channel blockers (tocolytic)
What should be avoided in patients with mitral or aortic insufficiency?
AVOID:
- Increase in SVR
- Decrease in contractility
- Bradycardia
What should be avoided in patients with mitral stenosis?
AVOID:
- Sinus tachycardia
- Atrial fibrillation
- Increases in blood volume
What should be avoided in patients with aortic stenosis?
AVOID:
- Decreases in SVR
- Bradycardia
- Hypovolemia
In general, which type of valvular disease is better tolerated in the pregnant patient stenotic or regurgitant?
Regurgitant
List three left to right shunts
- VSD
- ASD
- PDA
Name one right to left shunt
TOF (Tetralogy of Fallot)
What are the risk factors for gestational diabetes?
Advanced maternal age
Obesity
Family history
History of prior stillbirth, fetal malformation
What is the primary chronic effect on the fetus of a mother with gestational diabetes?
Macrosomia (Big baby)
What are the two most common structural malformations in fetuses born to mothers with gestational diabetes?
- Cardiac
2. CNS
How do infants generate heat without the ability to shiver?
Brown fat metabolism
80% pediatric cardiopulmonary arrests are due to what?
Respiratory distress
How does the pediatric larynx differ from an adult?
Funnel shaped larynx
Narrowest point = cricoid ring
At what age does obligate nasal breathing subside?
3 to 5 months
How does an infant’s epiglottis differ from an adult’s?
Infant = omega shaped and angled away from the axis of the trachea
Adult = broader
Where is the glottic opening relative to cervical vertebrae in the full-term infant? In the adult?
Full-term infant = C3, C4
Adult = C5, C6
How is an endotracheal tube sized in the pediatric population?
Diameter = 4 + (age/4)
How is the depth of an endotracheal tube determined in the pediatric population?
Where you hear bilateral breath sounds
Depth = 12 + (age/2)
At what pressure is it appropriate to have a leak in an uncuffed endotracheal tube?
15-25 cmH2O
Why has an uncuffed ETT been traditionally recommended in children less than eight years of age?
To avoid post extubation stridor and subglottic stenosis
However, requires more fresh gas flow and increases risk for aspiration
Why is airway edema of greater concern in the pediatric population?
Poiseuille’s law (R=8nl/π^4)
A decrease in the radius will have an even greater effect on resistance
Laryngotracheal stenosis occurs in what percent of prolonged pediatric intubations?
90%
What is the oxygen consumption of an infant?
6 mL/kg/min (2x adults)
True or False: Hypercarbia will stimulate ventilation in the term newborn
TRUE
What effect does hypoxia have on newborns?
< 2-3 weeks: Transient increase in ventilation followed by a sustained depression
> 3 weeks: Hypoxemia induces sustained hyperventilation
How is cardiac output controlled in the neonate?
HEART RATE Dependent
What is the normal blood volume for a premature infant, full-term neonate, 12 month infant?
Premie = 90-100 mL/kg
Full-Term Neonate = 80-90 mL/kg
12 mo Infant = 75-80 mL/kg
What are the normal blood pressure values for a neonate, 12 month old, 3 year old, 12 year old?
Neonate = 65/40
12 mo = 95/65
3 y/o = 100/70
12 y/o = 110/60
What are the normal heart rate values for a neonate, 12 mo, 3 y/o, 12 y/o?
Neonate = 140
12 mo = 120
3 y/o = 100
12 y/o = 80
What are the normal values for respiratory rate in a neonate, 12 mo, 3 y/o, 12 y/o?
Neonate = 40
12 mo = 30
3 y/o = 25
12 y/o = 20
What is the pediatric dose of atropine?
0.01-0.02 mg/kg IV
Min PALS dose 0.1 mg
What is the pediatric dose of succinylcholine?
2 mg/kg IV, 4 mg/kg IM
What is the pediatric dose of versed?
- 5 mg/kg PO
0. 1 mg/kg IV
What is the pediatric dose of rocuronium?
Same as adults
0.6-1.2 mg/kg IV
What is the pediatric dose of fentanyl?
1-2 mcg/kg IV
What is the pediatric dose of Zofran?
0.1 mg/kg IV
What is the pediatric dose of Ancef?
25-50 mg/kg IV
What are the pediatric fasting guidelines (in hours) for clear liquids and solids/milk?
Clear Liquids:
At least 2 hours
Solids, Milk, Formula:
< 6 mo = 4 hrs
6-36 mo = 6 hrs
> 36 mo = 8 hrs
At what age are MAC requirements highest?
Peak @ 1-6 mo
~1.8 MAC
Levels out @ 1-5 years
~ 1.6 MAC
What is the “rule of thumb” for caudal blocks?
Younger than 7 or less than 30 kg
When do most cardiac arrests occur in children in the operative setting?
During induction
What are two predictors of mortality in infants in the operative setting?
ASA class 3-5 Emergency status
At what point in gestation is pulmonary surfactant production sufficient?
> 35 weeks
What is an anesthetic concern common to premature infants?
Respiratory distress due to insufficient surfactant
What are two important considerations for airway management in a down syndrome child?
- Downsize the tube by 0.5
- Cervical instability
What are three important criteria for intraoperative management of a child with sickle cell disease?
- Warm
- Hydrated
- Pain-free
