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TOPICSII > EXAM 3 REVIEW > Flashcards

EXAM 3 REVIEW Flashcards

1
Q

Surfactant production : what types of cells?

A

Type II pneumocytes are responsible for the production and secretion of surfactant

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2
Q

When does surfactant production starts? when does concentration peak?

A

begins between 22 and 26 weeks, and concentrations peak between 35 and 36 weeks’ gestation.

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3
Q

Surfactant role is to ? what law describes how surfactant decreases surface tension?

A

decreases surface tension within the alveoli to decrease alveolar collapse. This relationship can be explained by the Law of Laplace

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4
Q

Can enhance surfactant maturation>?

A

Administration of Glucocorticoids in women in preterm labor can enhance the maturation process.

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5
Q

Surfactant production is sufficient in most cases by what week of gestation?

A

By 35 weeks gestation,

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6
Q

What is the major phospholipid of surfactant?

A

Dipalmitoyl lecithin

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7
Q

How do we test a pregnant mother to see if her baby’s lungs have reached maturity?

A

Look at the Lecithin:Sphingomyelin ratio in the amniotic fluid.

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8
Q

The incidence of PDPH and age

A

inversely related to age and seen infrequently in those older than 70 and younger than 10 years old.

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9
Q

Incidence of PDPH and GENDER

A

Women appear to be slightly more susceptible than men, and pregnancy may increase the incidence.

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10
Q

Incidence of PDPH needle diameter?

A

In general, large diameter needles are more likely to be associated with PDPH when compared with small-diameter needles.

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11
Q

A dural puncture with a 17-gauge epidural needle has a

A

70% PDPH rate compared with less than 1% with a pencil-point spinal needle.

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12
Q

With respect to spinal needles, the incidence of PDPH is significantly

A

reduced with the use of pencil-point needles (e.g., Pencan, Sprotte, Whitacre) compared with beveled cutting needles (e.g., Quincke).

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13
Q

PDPH air vs saline

A

occurred in 67% of the patients in the air group as opposed to 10% in the saline group

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14
Q

The angle at which the needle approaches the dura

may also

A

modify the amount of CSF leakage and therefore the

incidence of PDPH;

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15
Q

3 major risks for PDPH

A

Younger age (20-30 at higher risk)
Female Sex
Use of a CUTTING-TYPE needle

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16
Q

_______are not considered a first-line technique for neuraxial anesthesia due to the increased risk for PDPH

A

Continuous spinal anesthetics

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17
Q

Studies have shown that leaving the catheter in place for at least ________ reduces the incidence of headache after removal.

A

least 12 hours reduces the incidence of headache after removal.

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18
Q

Autonomic innervation of the neonatal heart

A

Autonomic innervation of the neonatal heart is predominantly controlled by the parasympathetic nervous system;

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19
Q

SNS and neonate

A

the sympathetic nervous system is immature at birth.

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20
Q

ANS dominance in neonate

A

Parasympathetic dominance produces bradycardia with minor clinical interventions such as pharyngeal suctioning and laryngoscopy

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21
Q

Marked variation in the newborn heart rate and rhythm occur secondary to

A

changes in autonomic tone.

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22
Q

At birth, vagal myelination occurs

A

more rapidly than sympathetic innervation. At birth, parasympathetic is more developed

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23
Q

AT birth When aortic arch and carotid baroreceptors are stimulated, there is a resulting

A

decrease in BP and slowing of the heart rate.

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24
Q

The autonomic nervous system activates

A

non-shivering thermogenesis in infants.

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25
Q

By what week of gestation is surfactant production sufficient enough to prevent respiratory distress syndrome in most infants?

A

By 35 weeks gestation, surfactant production is sufficient in most cases.

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26
Q

Compared to adults, the narrowest portion of the pediatric airway is at the

A

cricoid,

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27
Q

The level of the the relative vertical location of the larynx is

A

C2-C4 (C3-C6 in adults),

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28
Q

Epiglottis in the neonate

A

epiglottis is longer, more narrow, and stiff.

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29
Q

Neonate larynx is proportionately

A

smaller

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30
Q

When does the foramen ovale typically close?

A

Within one hour of life

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31
Q

In the normal, full-term infant, you would expect the glottis to be at the level of

A

C4

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32
Q

Select two reasons for low renal blood flow and glomerular filtration rate in utero.

A

Low glomerular capillary permeability

Small number of glomeruli

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33
Q

At birth the neonatal larynx is ______ compared with the mouth and pharynx

A

small compared with the mouth and pharynx.

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34
Q

The epiglottis is, and the

A

short and small

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35
Q

Neonate vallecula is

A

shallow so that the tongue approximates the epiglottis.

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36
Q

Mouth breathing vs nasal breathing

A

The larynx is pointed toward the nasopharynx, facilitating nasal breathing.

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37
Q

The arytenoids are

A

large in proportion to the lumen of the larynx.

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38
Q

The subglottic region is

A

smaller than the glottic opening with the cartilages telescoping into one another, forming a conical shape

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39
Q

Neonate: The narrowest portion of the airway, and the

cricoid lumen is not a

A

The cricoid cartilage

not round but mostly an ellipsoid structure

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40
Q

The newborn tongue is I

A

large and difficult to manipulate because of the position of the hyoid.

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41
Q

Neonatal submental

A

smaller potential submental space is present, in which it is possible to displace the tongue during laryngoscopy.

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42
Q

Larynx position and tongue of the neonate

A

The anterior position of the larynx and the large tongue increase the potential difficulty of mask
ventilation

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43
Q

Larynx is located more (caudad vs cephalad) and at what level of the Cspine?

A

cephalad and anterior, extending from the second to the fourth cervical vertebrae (C2 to C4)

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44
Q

The anesthetic implication of the more cephalad location is that

A

placing a neonate in the “sniffing position” for laryngoscopy and intubation will only move the larynx in an anterior direction.

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45
Q

The occiput of the newborn’s head is

A

large and prominent.

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46
Q

Neonate: what aids in the visual alignment of the oral, pharyngeal, and laryngeal axes during laryngoscopy

A

The placement of a rolled towel under the shoulders

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47
Q

Neonate laryngeal location

A

C2-C4

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48
Q

Neonate Right Mainstem bronchus

A

Less vertical

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49
Q

Full term infant GLOTTIS is at

A

C4

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50
Q

Preterm infant GLOTTIS is at

A

C3

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51
Q

Neonates and NDNMB

A

Increased sensitivity to the effects of NMBDs.

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52
Q

Why neonate have increased sensitivity to the NMBD? What happens to clearance and duration?

A

The increased volume of distribution means that a single NMBD dose for the neonate is the same as for the older child, but reduced clearance and increased sensitivity prolong duration.

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53
Q

Neuromuscular blocking drugs: ionization and lipophyilicity, implication.

A

highly ionized and have a low lipophilicity, which limits their ability to cross the bloodbrain barrier.

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54
Q

Because of NDNMB are highly ionized and have low liphophilicity These pharmacologic properties restrict the

A

distribution of neuromuscular blockers to the ECF compartment, which is larger in the neonate and infant than in the child and adult

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55
Q

Affect the pharmacokinetics and pharmacodynamics of neuromuscular blockers

A

Increases in ECF volume and the ongoing maturation of neonatal skeletal muscle and acetylcholine receptors

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56
Q

NMJ in neonate

A

The neuromuscular junction is incompletely developed

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57
Q

Infants requires ____doses of Succinylcholine why?

A

LARGER DOSE OF succinylcholine (2-3mg/kg) because of the LARGER VOLUME OF DISTRIBUTION

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58
Q

MR and onset of action for neonates

A

Faster onset of muscle relaxants because of a shorter circulation times than adults

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59
Q

Must be ALWAYS administered before succinylcholine if used.

A

ATROPINE 0.1 mg minimum

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60
Q

Response to NDNMB is variable due to

A

IMMATURITY OF THE NMJ tending to increase sensitivity , and a disproportionately LARGER extracellular compartment reducing drug concentration

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61
Q

Immaturity of the neonatal hepatic function

A

PROLONGS the duration of action for drugs that depend PRIMARILY on HEPATIC METABOLISM.

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62
Q

The acetylcholine receptors of the newborn are

A

anatomically different from the adult receptors, which may explain the sensitivity of the neonate to the nondepolarizing class of neuromuscular blocker

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63
Q

The increase in dose requirement for succinylcholine is in part a

A

result of the increased volume of distribution within the large extracellular compartment.

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64
Q

Neonates are more __________to the effects of succinylcholine than children and adults.

A

resistant

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65
Q

Plasma cholinesterase activity is __________in neonates

A

reduced

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66
Q

The duration of action after a single dose is of expected duration_________ A much prolonged duration of action after a single bolus
dose would suggest the y.

A

(6 to 10 minutes).presence of an inherited deficiency of plasma cholinesterase activity

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67
Q

Succinylcholine is only used for

A

emergency airway control in children under 12 years of age due to the risk of severe hyperkalemia in patients with undiagnosed myopathies

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68
Q

NDNMB reversal Adequacy: The rule of thumb is to observe

A

flexion of the elbows and hips,

knee to chest movements, return of abdominal muscle tone, andpresence of facial grimacing.

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69
Q

Neonates are capable of generating an .

A

MIF of −70 cm H2O with the first few

breaths after birth

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70
Q

An MIF of at least −32 cm H2O has been found to correspond with

A

leg lift, which is indicative of the adequacy

of ventilatory reserve required before tracheal extubation

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71
Q

When a child experience cardiac arrest after succinylcholine administration, immediate treatment for

A

HYPERKALEMIA should be instituted

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72
Q

Owing to the immaturity of the contractile elements of the

neonatal myocardium, the belief is that pediatric cardiac output

A

is solely dependent on heart rate

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73
Q

______is frequently administered for the treatment of decreased cardiac output.

A

Atropine

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74
Q

Marked increases in heart rate fail to a large extent to produce

A

further increases in cardiac output.

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75
Q

Produce dramatic decreases in cardiac output that threaten organ perfusion in neonates

A

The combination of hypovolemia and bradycardia

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76
Q

Epinephrine vs atropine in neonates

A

Epinephrine rather than atropine increases contractility and heart rate and is now advocated for the treatment of bradycardia and
decreased cardiac output in pediatric patients.

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77
Q

3 things that can cause increases in afterload ____, ____, ____ will produce further reductions in cardiac output (HAP)

A

(e.g., acidosis, hypothermia, pain)

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78
Q

SV and CO in neonates

A

Strove VOLUME is FIXED

CO is very sensitive to changes in HR

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79
Q

The neonate may develop congestive heart failure because the stiff

A

left ventricle will not stretch to accommodate large fluid loads

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80
Q

Left ventricular distention from volume overload compresses

A

the adjacent right ventricle, producing additional embarrassment to cardiac output.

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81
Q

The fetal circulatory system relies on the

A

placenta for delivery of oxygen and transport of carbon dioxide (CO2).

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82
Q

What is the functional unit of the placenta?

A

The chorionic villus is the functional unit of the placenta.

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83
Q

Normally, fetal blood is separated from the maternal blood in the placenta by a thin layer of cells known as

A

syncytial trophocytes.

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84
Q

Substances able to pass through placenta

A

Oxygen, CO2, and small nonionized particles readily pass through this layer, whereas substances with a larger molecular weight are prevented from diffusing across the syncytial
trophocytes.

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85
Q

Fetal circulation is characterized by

A

high pulmonary vascular resistance (uninflated atelectatic lungs and hypoxic vasoconstriction) and low systemic circulatory resistance (high flow and low impedance of the placental vessels)

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86
Q

Fetal deoxygenated blood travels

A

down the aorta and through the internal iliac arteries, arriving in the placenta via paired umbilical arteries.

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87
Q

The umbilical arteries divide, forming the

A

forming the arterioles, capillaries, and venules of the intervillous placental space.

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88
Q

Oxygenated blood is delivered to the fetus from the

A

placenta via a single umbilical vein.

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89
Q

Fetal circulation: This oxygenated blood bypasses the lungs by flowing through

A

extracardiac (ductus arteriosus, ductus venosus) and intracardiac (foramen ovale) shunts, forming a parallel circulation

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90
Q

The ductus venosus routes oxygenated

A

blood away from the sinusoids of the liver

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91
Q

The oxygenated blood in the inferior vena cava is directed by the

A

eustachian valve toward the atrial septum and passes through the foramen ovale to enter the left side of the circulation.

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92
Q

Oxygenated blood passes into the

A

left ventricle and exits the aorta, supplying the coronary arteries.

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93
Q

Blood entering the pulmonary artery from the right ventricle flows to the

A

aorta via the ductus arteriosus.

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94
Q

Only ____to ___%of the combined ventricular output flows through the pulmonary circulation.

A

5% to 10%

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95
Q

The pathologic mechanism factors is

A

increased pulmonary vascular resistance (PVR) and right-to-left shunting

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96
Q

Normal PaO2 from umbilical artery is

A

20-30 mmHg

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97
Q

Normal O2 saturation is about (in umbilical artery)

A

40%

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98
Q

Fetal hgb and 2,3 DPG

A

Does not bind to 2,3 DPG

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99
Q

The ductus arteriosus is a fetal connection between the

A

pulmonary artery and the descending aorta

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100
Q

When does the foramen ovale typically close?

A

Within 1 hour of life as LA pressure exceed RA pressure

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101
Q

Fetal Hgb replaced by adult Hgb by

A

3-4 mths

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102
Q

While in utero, what keep the ductus arteriosus open.?

A

prostaglandins

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103
Q

Resting cardiac output in the newborn is approximately_____This means faster

A

200 mL/kg/ min. Means faster circulation times that are capable of delivering and removing drugs from their sites of action at a higher rate.

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104
Q

The minimum alveolar concentration (MAC) of the inhalation anesthetics is

A

less in neonates than in infants.

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105
Q

Neonates have a somewhat_____when does it peak?

A

lower MAC, which peaks at around 30 days of age and decreases thereafter

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106
Q

MAC is greater in infants than in

A

neonates and adults

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107
Q

MAC is the HIGHEST at

A

6 months of age

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108
Q

Airway resistance is greater in

A

neonates and declines markedly with growth from 19 to 28 cm H2O/L/sec to less than 2 cm H2O/L/ sec in adults.

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109
Q

Airway resistance and law

A

According to Poiseuille’s law, airway resistance

is inversely proportional to the fourth power of the radius of the airway during laminar flow.

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110
Q

A neonate must overcome the

A

resistance to airflow, as well as the elastic recoil of the lungs and chest wall.

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111
Q

The rate of ventilation that uses the least amount of muscular
energy and generates a satisfactory tidal volume has been found to be

A

37 breaths per minute in the healthy newborn.

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112
Q

The metabolic cost of breathing in the neonate is similar to

an adult, approximately

A

0.5 mL per 0.5 L of ventilation.

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113
Q

Airway resistance changes with

A

age.

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114
Q

Although the larger airway resistance remains constant, airway resistance in the smaller airways is

A

increased.

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115
Q

The increase in airway resistance and neonate

A

increases the work of breathing in the neonate.

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116
Q

Small airway disease (e.g., pneumonia) produces

A

additional increases in the work of breathing.

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117
Q

Myocardial contractility/ compliance in Neonate

A

↓ Myocardial contractility/↓ myocardial

compliance

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118
Q

Myocardial depression may be exaggerated when

A

inhalation anesthetics are administered to pediatric patients

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119
Q

Not recommended during resuscitation of the depressed neonate is

A

naloxone

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120
Q

Higher doses of epinephrine can lead to decreased myocardial function at doses in the range of

A

0.1 mg/kg IV with EPINEPHRINE

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121
Q

2 patients who have a greater risk of central apnea.

A

patients who were born before 36 weeks’ gestation and whose postconceptual age is less than 60 weeks

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122
Q

For this reason, these patients should bes.

A

kept overnight

for observation after any surgical procedure

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123
Q

The risk of apnea if the patient has

A

received regional anesthesia versus receiving general anesthesia is less; however, these patients should be admitted and monitored postoperatively as well

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124
Q

Administration of what 2 to a less than 60 weeks PCA, MOST DECREASE the RISK of POSTOPERATIVE APNEA →

A

CAFFEINE and CPAP

125
Q

Neonate should be hospitalized and monitored for

A

24 hours after surgery as a single dose of caffeine may not provide sufficient protection against apnea

126
Q

What put a less than 60 weeks PCA more at risk for apnea →

A

PREOPERATIVE ANEMIA such as hematocrit less than 30%, hx of apnea, or hx of apnea at home

127
Q

ALL infants younger than 60 weeks PCA should be

A

monitored for at least 24 hours after surgery.

128
Q

The HIGHEST RISK for POSTOPERATIVE apnea and BRADYCARDIA is within

A

6 hours of surgery and can be seen up to 12 hours after surgery.

129
Q

PCA babies, ALL elective surgery should be

A

delayed until they are older than 60 weeks PCA

Apnea is strongly and inversely related to both gestation and PCA

130
Q

During what period following general anesthesia are premature neonates most likely to exhibit apnea and bradycardia?

A

4-6 hours

131
Q

Most STRONGLY associated with an increased RISK OF CENTRAL POSTOP APNEA is →

A

ANEMIA, SEPSIS, hypothermia

132
Q

Premature EBV

A

90-100

133
Q

Newborn EBV (less than 1 mo of age)

A

80-90

134
Q

Infants 3 mo to 3 yr EBV

A

75-80

135
Q

Preterm neonate ETT size

A

2.0-3.0

136
Q

Full-term neonate ETT size

A

3.0-3.5

137
Q

3 months to 1 year of age ETT size

A

4.0

138
Q

Neonate intubation preferable blade

A

straight blade preferable.

139
Q

Intubating neonates steps

A

blade is placed along the right side of the mouth sweeping the tongue to the left. The epiglottis is picked up with the tip of the blade and the tracheal inlet exposed. The tube is inserted with the convex side to the left. When the tip approaches the glottic opening, rotate the tube 90 degrees counterclockwise. The advantage of one over another is the characteristic that allows the large tongue of the neonate to be manipulated out of the visual field.

140
Q

There are also modifications of straight blades that allow

A

insufflation of oxygen into the pharynx during intubation

141
Q

Cleft lip, with or without cleft palate, may

A

complicate intubation.

142
Q

If there is concern for difficult airway,

A

awake intubation should be considered.

143
Q

can obstruct the airway during mask ventilation.

A

The small mouth and large tongue

144
Q

Neonates have very

A

small nares, and when obstructed by an anesthesia facemask, they do not convert
to mouth breathing, particularly if the mouth is being held closed.

145
Q

May make direct laryngoscopy and visualization of the glottis impossible, requiring other types of airway management

A

small and/or receding chin, as seen in Pierre

Robin and Treacher Collins syndromes,

146
Q

____can obstruct half of the neonate’s airway and should be placed_____

A

A nasogastric tube ; orally

147
Q

Anomalies such as _______or _______

of the neck can produce upper airway obstruction

A

cystic hygroma or hemangioma

148
Q

Neonate head: can make airway management difficult.

A

The shape and size of the head, with

or without the presence of pathology,

149
Q

Two types of muscle fibers are present in muscle tissue—specifically,

A

the diaphragm and intercostals.

150
Q

Type 1 muscle fibers are

A

slow twitch muscle fibers and are resistant to fatigue.

151
Q

These fibers are essential for sustained ventilatory activity.

A

Type 1

152
Q

Type 2 muscle fibers, also known as

A

fast twitch muscle fibers, are fast twitch but fatigue rapidly.

153
Q

A newborn infant’s diaphragm is composed of

A

25% type 1 muscle fibers as compared to 55% type 1 muscle fibers in the adult diaphragm.

154
Q

Neonates: Also, type 2 muscle fibers are predominant within

A

the intercostals.

155
Q

A newborn infant’s diaphragm is composed of 25% type 1
muscle fibers as compared to 55% type 1 muscle fibers in the adult diaphragm. Also, type 2 muscle fibers are predominant within the intercostals. Therefore, newborns and young infants are at

A

risk of muscle fatigue, respiratory distress, and respiratory arrest

156
Q

Allow for expansion of the thoracic cavity and the associated
increase in negative intrathoracic pressure in neonates

A

Primarily the diaphragm and to a lesser extent the intercostal muscles

157
Q

The boxlike configuration of an infant’s thorax permits

A

less elastic recoil than the dorsoventrally flattened thoracic cage of the adult does

158
Q

The oxyhemoglobin curve of a newborn is shifted to the

A

left compared to that of an adult because of the PRESENCE of FETAL HEMOGLOBIN which has a HIGHER AFFINITY FOR OXYGEN

159
Q

During the first 3-6 months of life, the oxyhemoglobin curve begins to shift to the

A

right, which helps compensate for the anemia of infancy.

160
Q

Careful monitoring of what may be needed to maintain

oxygenation during surgery?

A

the acid-base status, the use of increased peak inspiratory pressure, and positive end-expiratory pressure

161
Q

Will attenuate the increase in pulmonary vascular resistance

A

Oxygenation
Avoidance of acidosis
Maintenance of normothermia

162
Q

A _____level is sufficient for performing a cesarean section under epidural anesthesia.

A

A T4 level

163
Q

A dermatomal level required to provide effective anesthesia for cesarean section.

A

T4

164
Q

After a negative test dose and careful aspiration for blood and CSF Lidocaine dose and epinephrine concentration?

A

lidocaine 2% with epinephrine 1:200,000 can be used when dosed in 3- to 5-mL increments.

165
Q

Volume required for a T4 Level?

A

A total volume of approximately 20 to 25 mL is required to obtain a T4 level.

166
Q

Bupivacaine is generally

A

avoided due to the increased maternal mortality associated with it when toxicity occurs

167
Q

Pain pathway during labor: Uterus and cervix innervation is

A

T10 to L1-L2, pain impulses

168
Q

First stage of labor pain carried by

A

carried by visceral afferent type C fibers

169
Q

Pain impulses carried by somatic nerve fibers , pudental nerves.

A

Perineum pain S2 - S4

170
Q

Preterm labor is defined as

A

Delivery before 37 weeks of gestation

171
Q

Preterm labor diagnosis is facilitated by measuring

A

Fetal fibronectin and maternal cervical ultrasonography

172
Q

As a general rule, if tocolytics are given, they should be given

A

concomitantly with corticosteroids.

173
Q

A patient is receiving tocolytic therapy or preterm labor. Which of the following is most concerning or this patient?

A

PULMONARY EDEMA

174
Q

Drugs administered to treat preterm labor and STOP uterine contractions that interfere with fetal oxygen

A

Terbutaline

175
Q

Procedures that are associated with the greatest incidence of preterm labor.

A

Abdominal and pelvic procedures

176
Q

Most likely to be associated with preterm labor

A

Intra-abdominal procedures during the third trimester

177
Q

Preterm labor parturients consider

A

preterm labor may allow time for the onset of the therapeutic effect of corticosteroids.

178
Q

The cause of preterm labor is not well understood; however, four pathways are:

A

Myometrial and fetal membrane overdistention
Decidual hemorrhage
precocious fetal endocrine activation, and
intrauterine infection or inflammation

179
Q

Lipid Emulsion Therapy initial dose and maintenance

A

IV bolus of 1.5 ml/kg of 20% lipid emulsion is given OVER 1 minute, FOLLOWED BY an infusion of 0.25 ml/kg/min until AT LEAST 10 MINUTES AFTER SUCCESSFUL ACHIEVEMENT of CIRCULATORY STABILITY.

180
Q

A major component of resuscitation, because cardiac arrest from LAST is different than typical out of the hospital cardiac arrest

A

20% lipid emulsion

181
Q 
Parturient Changes in airway begin at
There are NO PREDICTORS of increasing airway class and no association between amount of WEIGHT gain
A

12 weeks of gestation

182
Q

Airway changes in parturient in caused by

A

CAPILLARY ENGORGEMENT of the mucosa causes AIRWAY EDEMA and INCREASED FRIABILITY

183
Q

ET tube for the parturient

A

SMALLER Endotracheal tube (6.0 - 6.5) necessary

184
Q

What is contraindicated to do in the parturient airway and why?

A

INCREASED Friability makes the NASAL mucosa MORE FRIABLE making NASAL INTUBATION relatively CONTRAINDICATED

185
Q

Number of patients with mallampati class III or IV airways increases dramatically between

A

12 and 38 weeks of gestation

186
Q

WHILE further worsening of MALLAMPATI class occurring during

A

active labor

187
Q

PREDICTORS of increasing airway class

A

There are NONE and no association between amount of WEIGHT gain

188
Q

Placenta accreta is the

A

abnormal implantation of the placenta into the uterine wall

189
Q

Placenta accreta is associated with

A

Increasing cause for MATERNAL HEMORRHAGE and requirement for PERIPARTUM HYSTERECTOMY

190
Q

Parturient at risk for Placenta Accreta

A

OVERALL risk as high as 60% in women with a NUMBER OF PREVIOUS C-SECTION (3 or more)
HX of PLACENTA PREVIA

191
Q

Which is true of pain associated with the second stage of labor? Think SS

A

IT IS SOMATIC (Second-Somatic)

192
Q

The second stage of labor starts when the

A

cervix is fully dilated to 10 cm and ends when the fetus is delivered.

193
Q

Pudental nerve distribution

A

Pudental nerve distribution of the pelvic floor S2-S4

194
Q

Pain from the second stage of labor is somatic, includes the

A

S2-S4 spinal cord segments,

195
Q

2nd stage labor pain is caused by

A

by stretching of the perineum, fascia, skin, and subcutaneous tissue.

196
Q

2nd stage labor pain mediated by

A

Affarent nerve conducted along the pudental nerves S2-S4

197
Q

Volatile anesthetics agents are advantageous for maintenance of anesthesia because of

A

uterine relaxation and prevent premature labor

198
Q

Gas that has no effect on uterine relaxation

A

Nitrous oxide

199
Q

VA and uterine relaxation

A

All volatile anesthetics promote uterine relaxation in a dose-dependent manner.

200
Q

MAC and uterine relaxation

A

1.5 MAC of volatile agent, uterine contractility is Decreased by 50%

201
Q

Which of the following interventions would be an alternative to administering an inhalation agent to facilitating uterine relaxation in a parturient?

A

NITROGLYCERIN

202
Q

Which of the following would be considered an average blood loss from an uncomplicated cesarean section?

A

1000 ml (1L)

203
Q

The average blood loss for a vaginal delivery is and for

A

500 mL

204
Q

Average blood loss for an an uncomplicated cesarean section, the blood loss is

A

800 to 1000 mL.

205
Q

Normal blood losses at delivery are generally well tolerated in the healthy parturient as a result of

A

compensatory mechanisms

206
Q

Pain experience during the first stage of labor, mostly caused by

A

UTERINE CONTRACTION and DILATION of the CERVIX

207
Q

First stage labor Pain is PRIMARILY transmitted via

A

SYMPATHETIC FIBERS ORIGINATING from T10 - L1

208
Q

Pain from the first stage of labor is visceral, involves spinal cord segments T10-L1, and is caused by

A

traction on the round ligament, cervical dilation, and uterine contractions.

209
Q

First stage of labor pain begins with

A

Onset of regular painful contractions and ends at complete dilation of the cervix.

210
Q

First stage of labor pain is what type of pain

A

VISCERAL.

211
Q

Increase in CO during pregnancy is due to
SVR decreases by as much as 21% by term. Much of this change is due to the decreased resistance in the vasculature of the uterus, placenta, kidneys, and lungs.

A

increase in STROKE VOLUME

212
Q

Pregnancy and CO

A

CO increases by 40%

213
Q

Cardiovascular changes begin as early as the

A

fourth week of pregnancy; then continue into the postpartum period

214
Q

The heart rate is increased by______ at term.

When a woman
is in labor, cardiac output increases during uterine contractions
as a result of autotransfusion from the contracting uterus to the
central circulation.10

A

20% to 30%

215
Q

HR: This increase in HR begins in the ______and peaks by

A

first trimester ;32 weeks of gestation.

216
Q

Normal heart rate (HR) variability does not appear to be changed until late in pregnancy, when

A

tachyarrhythmias are more common

217
Q

Cardiac output increases by approximately

A

40% over nonpregnant values.

218
Q

This increase in cardiac output begins in the

A

fifth week of pregnancy and results from an increase in stroke volume (SV) 20%-50%) and, to a lesser extent, heart rate.

219
Q

Some studies previously indicated cardiac output decreased in the third trimester, but these results were likely due to

A

aortocaval compression from studying subjects in the supine position

220
Q

At term, approximately __% of the CO perfuses the gravid uterus.

A

10-15 % of the cardiac output perfuses the gravid uterus.

221
Q

When a woman is in labor, cardiac output increases during uterine contractions as a result of

A

autotransfusion from the contracting uterus to the

central circulation.

222
Q

When a woman is in labor, CO

A

Increases during uterine contractions.

223
Q

Immediately after delivery, What happens to the cardiac cardiac output?

A

increases as much by as 80% above predator values as a result of an increase in central volume from the now contracted uterus and relief of aortocaval compression.

224
Q

Immediately after delivery, CO increases by as much as 80% , what are the implications ?

A

As a result, patients with preexisting cardiac anomalies

are at an increased risk for decompensation in the immediate postpartum period.

225
Q

Cardiac output gradually returns to baseline within

A

14 days as HR and SV normalize

226
Q

During pregnancy the diaphragm what happens to the heart.?.

A

rises, shifting the heart up and to the left, making the cardiac silhouette appear enlarged on x-ray examination

227
Q

Ventricular walls and EDV in pregnant women

A

The ventricular walls thicken and end-diastolic

volume increases

228
Q

PE of pregnant patients: Heart

A

A benign grade 1 or 2 systolic murmur or a third heart sound may be heard on auscultation

229
Q

When is a murmur in a parturient requires further evaluation?

A

If the systolic murmur is greater than grade 3 or accompanied by chest pain or syncope, further evaluation is necessary

230
Q

2 things that are pathologic and not normal in the parturient heart?

A

Diastolic murmurs and cardiac enlargement are considered pathologic.

231
Q

Normal pregnancy also may result in signs of cardiac abnormality such as

A

exercise intolerance, shortness of breath, and edema.

232
Q

Pregnant women and BARORECEPTOR reflexes

A

baroreflex-mediated changes. in HR at term than at 6 to 8 weeks postpartum

233
Q

In the presence of adequate neuraxial analgesia and little sympathetic stimulation, there is often a corresponding decrease in

A

maternal heart rate during uterine contractions due to the transiently increased preload

234
Q

Systemic vascular resistance (SVR) and parturient

A

decreases as much as 21% by the end of a term pregnancy, owing in large part to decreased resistance in the uteroplacental, pulmonary, renal, and cutaneous
vascular beds.

235
Q

At term gestation of _____% of the cardiac output

perfuses the low resistance intervillous space of the uterus

A

10%

236
Q

Venous capacitance and Pregnant women

A

The venous capacitance system loses tone, allowing pooling of the larger blood volume.

237
Q

This decrease in SVR results in little

A

overall systolic blood pressure change during normal pregnancy, despite the increased blood volume.

238
Q

DBP and pregnant women

A

A decrease in diastolic blood pressure of up to 15 mmHg may occur, resulting in a decrease in mean pressure.

239
Q

Supine hypotensive syndrome in a parturient is most likely to occur at

A

36-38 weeks

240
Q

Select two physiologic characteristics that you would expect to be decreased in the obstetric patient at term →

A

Hgb, SBP

241
Q

The platelet count and pregnancy

A

decreases during pregnancy due to dilution and an increase in platelet consumption. Between 10 and 15% of term parturients will have a platelet count less than 150,000.

242
Q

By term, plasma volume________by _____%

A

ncreases by about 40 percent,

243
Q

Term and Hemoglobin

A

decreases to 11-12 g/dL

244
Q

Term and fibrinogen

A

Doubles

245
Q

2 changes in term pregnancy that maximize oxygen delivery?

A

The increased cardiac output and a shift to the right in the oxyhemoglobin dissociation curve help to maximize oxygen delivery.

246
Q

-During labor , CO further increases _____% over the pre-labor values in the first stage and up to _____% in the 2nd stage, and as high as _____% immediately after delivery.

A

10-25% over pre-labor values in the first stage and up to 40% in the 2nd stage, and as high as 80% immediately after delivery

247
Q

BV is increased by up to

A

45% over Pre-pregnancy values (range in 30-50%)

248
Q

BV increases by what leads to dilutional anemia?

A

Red cell volume increases by only 30% leading to PHYSIOLOGIC ANEMIA of pregnancy

249
Q

TOTAL BLOOD VOLUME and pregnancy

A

increase by 25-40%

250
Q

BV increased is due to

A

HIGH aldosterone secondary to RAAS upregulation.

251
Q

Blood volume is markedly

A

MARKEDLY INCREASED AND PREPARES THE PARTURIENT FOR THE BLOOD LOSS associated with delivery

252
Q

Plasma volume and pregnancy

A

increases by 40%

253
Q

Plasma volume is increased to a greater extent than

A

Red Blood cell volume resulting in a delusional anemia.

254
Q

Erythrocyte mass change

A

increases by about 20%

255
Q

Decreased HEMATOCRIT referred to as physiologic anemia Because the

A

red blood cell mass only increases by about 20%, there is a relative anemia present.

256
Q

Plasma volume increases by ___%during pregnancy while erythrocyte mass increases by about ___%. The relatively smaller increase in red blood cell mass leads to a

A

40% ; 20%; decreased hematocrit, referred to as the physiologic anemia of pregnancy.

257
Q

The increased plasma volume is likely the result of

A

greater circulating levels of progesterone and estrogen resulting in enhanced renin-angiotensin-aldosterone activity

258
Q

Systolic Blood pressure and pregnancy

A

decreases by 5%

259
Q

Pregnancy: Increase in SVR results in little overall

A

systolic blood pressure change during normal pregnancy, despite the increased blood volume

260
Q

Maternal stroke volume index, heart rate,

and systolic blood pressure were

A

higher in the lateral positions compared with the sitting and supine-tilt positions

261
Q

All pregnant women are at increased risk of aspiration and should be considered to

A

because of the anatomic and physiologic changes to the gastrointestinal system

262
Q

All pregnant women should be considered to ____starting after ______weeks of gestation

A

have a full stomach after week 12 of gestation.

263
Q

Maternal intubation

A

Rapid sequence induction with a rapid acting muscle relaxant (succinylcholine). Pre-oxygenate but do hand ventilated, maintain cricoid pressure until intubation is achieve and the cuff is inflated.

264
Q

High doses of oxytocin can produce

A

diastolic hypotension (and some degree of systolic hypotension), flushing, and tachycardia.

265
Q

By what week of gestation is surfactant production sufficient enough to prevent respiratory distress syndrome in most infants?

A

35 weeks

266
Q

What is the most reliable test for detecting an inadvertent intrathecal or intravascular epidural catheter placement in a laboring parturient?

A

Negative aspiration for CSF or blood

267
Q

During the third trimester of pregnancy, the cardiac output

A

increases primarily due to an increase in stroke volume

268
Q

Plt count considered too low to perform a neuraxial anesthetic.

A

A platelet count less than 75,000-80,000 is

269
Q

The drug of choice for treating hypertension during anesthesia in a parturient with preeclampsia is

A

Labetalol

270
Q

What sensory level block would be appropriate for performing a cesarean section under epidural anesthesia?

A

T4

271
Q

Which of the following parameters increases with pregnancy?

A

PaO2

272
Q

How long after delivery does the cardiac output of the mother remain elevated?

A

14 days

273
Q

Which of the following is associated with a higher risk of placenta accreta in parturients already presenting with placenta previa?

A

History of multiple cesarean sections

274
Q

Which is the most common epidural test dose of local anesthetic (LA) containing epinephrine?

A

3 mL of LA containing 5 mcg/mL (1:200,000) of epinephrine

275
Q

The epinephrine in an epidural test dose is less reliable in which patient class?

A

Patients in active labor

276
Q

Recommended for pregnant women receiving general anesthesia from In such a case, an alternative method, such as
awake intubation, may be necessary

A

Rapid sequence induction, cricoid pressure, and a cuffed endotracheal tube are

277
Q

RSI starting ___Weeks of gestation

A

20 WEEKS on even if no symptoms of reflux are present.

278
Q

Although rapid-sequence induction is the technique most commonly used to minimize the risk of gastric aspiration during induction of general anesthesia, it is not indicated if

A

Laryngoscopist has doubts about his or her ability to

intubate the patient.

279
Q

If questioning ability to intubate

A

In such a case, an alternative method, such as

awake intubation, may be necessary

280
Q

Intravenous rapid sequence induction:

A
  • Cricoid pressure
  • Propofol, ketamine, or etomidate
  • Succinylcholine (rocuronium or vecuronium if succinylcholine is contraindicated)
281
Q

Pregnant Intubation with a______ to ______ETT

A

6.0- to 7.0-mm cuffed endotracheal tube

282
Q

The muscle relaxant of choice during the rapid-sequence induction of an obstetric patient.

A

Succinylcholine

283
Q

In pregnant patients on magnesium therapy, how do you modify the intubation?

A

defasciculation with a small dose of a nondepolarizing neuromuscular blocking agent is not recommended because significant paralysis may result, increasing the risk of aspiration of gastric contents.

284
Q

Magnesium potentiates

A

depolarizing and, especially, nondepolarizing relaxants.

285
Q

For TEST dose, Administer

A

3ml and observe for maternal heart for 60 seconds and level of block for 3-5 minutes. If no sign for subarachnoid or intravascular injection, administer 3-5 ml and observe for 3-5 minutes.

286
Q

When administered intravascularly , lidocaine 45 mg will often results in early signs and symptoms of modest systemic toxicity such as

A

CIRCUMORAL NUMBNESS
LIGHTHEADEDNESS
AUDITORY CHANGES

287
Q

Commonly administered test dose is 3ml of lidocaine 1.5% with epinephrine 1:200,000. Lidocaine ____mg and ____mcg of epinephrine

A

This is 45 mg dose of lidocaine, 15mcg of epinephrine

288
Q

Test dose is done to identify epidural catheters that are

A

inadvertently inserted into either the subarachnoid space or an epidural vein

289
Q

Test dose

A

Reveal inadvertent subarachnoid or intravascular injection

290
Q

In laboring patients, test dose

A

increases in HR are less specific indicators of intravascular injection because of the changes in HR that normally occur with uterine contractions.

291
Q

Epinephrine may cause significant

A

uterine artery constriction in a small number of patients, resulting in a decrease in fetal O2 delivery.

292
Q

Without administration of a test dose, may be effective in revealing intrathecal or intravascular catheter.

A

Careful aspiration for blood or CSF alone,

293
Q

Test dose required when administering

A

LARGER and MORE CONCENTRATED DOSES, such as giving an epidural for cesarean delivery.

294
Q

Reliability impaired in the face of B-Blockade,

A

advanced age and active labor.

295
Q

Use an alternative to patients with B-Blockade

A

Fentanyl

296
Q

Use minimum ED, careful aspiration,

A

incremental injection, coupled with the use of intravascular markers when large doses are used.

297
Q

For neonate Administration of _________prior to the administration of the TEST dose may increase the sensitivity of the test dose.

A

ATROPINE 10mcg/kg

298
Q

You are preparing to place an epidural catheter in an obstetric patient who is taking metoprolol. Which of the following would be the best formulation for an epidural test dose?

A

Although epinephrine reliably increases the heart rate in pregnant patients, it is less specific in laboring patients because the heart rate varies widely during and between labor contractions. Also, in patients taking beta-blockers, it may not be very effective. In those instances, the use of fentanyl to see if sedation is produced is an alternative.

299
Q

After IV, exposing an infant to 0.5mc/kg of epinephrine during sevoflurane anesthesia, the most likely changes that mark an intravascular injection are

A

1) Elevated in T-wave amplitude by 25% (MOST SENSITIVE)
2) an increase in HR by 10bpm
3) increase in systolic blood pressure by 15mmHg.

300
Q

Most appropriate test dose of epinephrine for a 5 kg 3 month old is

A

2.5 mcg (0.75mcg/kg)

301
Q

The epinephrine in an epidural test dose is less reliable in which patient class?

A

less specific in laboring patients because the heart rate varies widely during and between labor contractions.

302
Q

Postdural puncture headache is generally relieved by assuming a

A

Lying position

303
Q

P50 in the mother

A

Increases and go to the RIGHT

304
Q

P50 in the fetus

A

Decreases and go to the LEFT>

305
Q

MAC peak at the highest

A

2-3 months.

306
Q

Vd in neonate

A

Large

307
Q

Protein binding in neonate

A

Decreased (INCREASE FREE DRUG LEVELS)

308
Q

Body fat % in neonate

A

Decreased

309
Q

Renal and hepatic function in the neonate

A

immature

TOPICSII (4 decks)

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