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ob exam 1 > Module 3: Part 4 > Flashcards

Module 3: Part 4 Flashcards

1
Q

Why is mom able to walk with a walking epidural with fentanyl?

A

No motor block

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2
Q

What type of epidural may be good in early labor?

A

walking epidural with fentanyl

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3
Q

Which epidural is the mom not confined to the bed with?

A

walking epidural with fentanyl

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4
Q

Which type of epidural is done when patient is in late stages of labor?

A

combined spinal-epidural

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5
Q

When replacing an epidural that didn’t work well during labor and when you need quick analgesia which epidural type should be used?

A

combined spinal-epidural

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6
Q

regular epidural

A
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7
Q

Which position gives better visualization of midline, especially in the obese and pregnant patient or difficult to palpate?

A

sitting

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8
Q

Which position is usually better for maternal comfort?

A

sitting

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9
Q

For which position should patient arch like a cat, the letter C, cannonball?

A

sitting

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10
Q

T/F Sitting position has fewer effects on uteroplacental perfusion

A

FALSE
lateral has Fewer effects on uteroplacental perfusion

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11
Q

T/F Lateral position is the easiest to maintain

A

TRUE

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12
Q

less intravascular catheter placements are a/w which position?

A

lateral

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13
Q

lumbar lordosis

A
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14
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE 1

A

GUIDELINE I
NEURAXIAL ANESTHESIA SHOULD BE INITIATED AND MAINTAINED ONLY IN LOCATIONS IN WHICH APPROPRIATE RESUSCITATION EQUIPMENT AND DRUGS ARE IMMEDIATELY AVAILABLE TO MANAGE PROCEDURALLY RELATED PROBLEMS.

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15
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE 2

A

GUIDELINE II
NEURAXIAL ANESTHESIA SHOULD BE INITIATED AND MAINTAINED BY A PHYSICIAN WITH APPROPRIATE PRIVILEGES OR UNDER THE MEDICAL DIRECTION OF SUCH AN INDIVIDUAL.

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16
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE 3

A

GUIDELINE III
NEURAXIAL ANESTHESIA SHOULD NOT BE ADMINISTERED UNTIL: (1) THE PATIENT HAS BEEN EXAMINED BY A QUALIFIED INDIVIDUAL; AND (2) A PHYSICIAN WITH OBSTETRIC PRIVILEGES TO PERFORM OPERATIVE VAGINAL OR CESAREAN DELIVERY, WHO HAS KNOWLEDGE OF THE MATERNAL AND FETAL STATUS AND THE PROGRESS OF LABOR AND WHO AGREES WITH THE INITIATION OF LABOR ANESTHESIA, IS READILY AVAILABLE TO SUPERVISE THE LABOR AND MANAGE ANY OBSTETRIC COMPLICATIONS THAT MAY ARISE.

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17
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE 4

A

GUIDELINE IV
AN INTRAVENOUS INFUSION SHOULD BE ESTABLISHED BEFORE THE INITIATION OF NEURAXIAL ANESTHESIA AND MAINTAINED THROUGHOUT THE DURATION OF THE NEURAXIAL ANESTHETIC.

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18
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE V

A

NEURAXIAL ANESTHESIA FOR LABOR AND/OR VAGINAL DELIVERY REQUIRES THAT THE PARTURIENT’S VITAL SIGNS AND THE FETAL HEART RATE BE MONITORED AND DOCUMENTED BY A QUALIFIED INDIVIDUAL. MONITORING TECHNIQUE, FREQUENCY OF RECORDING, AND ADDITIONAL MONITORING SHOULD BE CHOSEN WITH REGARD TO THE CLINICAL CONDITION OF THE PARTURIENT AND FETUS AND IN ACCORDANCE WITH INSTITUTIONAL POLICY. WHEN EXTENSIVE NEURAXIAL BLOCKADE IS ADMINISTERED FOR COMPLICATED VAGINAL DELIVERY, THE STANDARDS FOR BASIC ANESTHETIC MONITORING SHOULD BE APPLIED.

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19
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE VI

A

NEURAXIAL ANESTHESIA FOR CESAREAN DELIVERY REQUIRES THAT THE STANDARDS FOR BASIC ANESTHETIC MONITORING BE APPLIED AND THAT A PHYSICIAN WITH PRIVILEGES IN OBSTETRICS BE IMMEDIATELY AVAILABLE.

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20
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE VII

A

QUALIFIED PERSONNEL, OTHER THAN THE ANESTHESIA PROVIDER ATTENDING THE MOTHER, SHOULD BE IMMEDIATELY AVAILABLE TO ASSUME RESPONSIBILITY FOR RESUSCITATION OF THE NEWBORN.

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21
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE VIII

A

A PHYSICIAN WITH APPROPRIATE PRIVILEGES SHOULD REMAIN READILY AVAILABLE DURING THE NEURAXIAL ANESTHETIC TO MANAGE ANESTHETIC COMPLICATIONS UNTIL THE PATIENT’S POSTANESTHESIA CONDITION IS SATISFACTORY AND STABLE.

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22
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE IX

A

ALL PATIENTS RECOVERING FROM NEURAXIAL ANESTHESIA SHOULD RECEIVE APPROPRIATE POSTANESTHESIA CARE. FOLLOWING CESAREAN DELIVERY AND/OR EXTENSIVE NEURAXIAL BLOCKADE, THE STANDARDS FOR POSTANESTHESIA CARE SHOULD BE APPLIED.

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23
Q

American Society of Anesthesiologists Guidelines for Neuraxial Anesthesia in Obstetrics: GUIDELINE X

A

THERE SHOULD BE A POLICY TO ASSURE THE AVAILABILITY IN THE FACILITY OF A PHYSICIAN TO MANAGE COMPLICATIONS AND TO PROVIDE CARDIOPULMONARY RESUSCITATION FOR PATIENTS RECEIVING POSTANESTHESIA CARE.

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24
Q

What are the procedure steps for placing an epidural?

A
  1. Time out
  2. Position, find spot, sterile prep and drape
  3. Lidocaine 1% local (with/without bicarb) to interspace
  4. # 17 gauge Touhy using ”loss of resistance technique “ (LORT) with either air or saline in a glass or plastic syringe
  5. Once LORT, 2-4 cc of saline can be injected slowly to ”tent” the space
  6. Catheter insertion
  7. Test dose
  8. Sterile dressing
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25
Q

2-4 cc of saline can be injected slowly to ”tent” the space (before/after) loss of resistance technique is performed.

A

AFTER

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26
Q

For the epidural procedure you should use what needle (type and gauge)?

A

17 gauge Touhy

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27
Q

Anatomy for Epidural Procedure

A
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28
Q

Epidural Placement Visual

A
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29
Q

Epidural Hand Placement

A
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30
Q

Why do we do a test dose with epidurals?

A

To identify unintentional cannulation of a vein or subarachnoid space by the needle or catheter

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31
Q

The test dose normally consists of what meds?

A

Local anesthetic and usually epinephrine (Lido 1.5% with 1:200,000 epi, 3 cc)

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32
Q

If you get a positive test dose what s/s would you see?

A

reliably causes about a 20 beat increase in HR over baseline in 45 seconds, if positive test dose

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33
Q

If you give an intravascular test dose what s/s would you see? (4)

A

increase in HR and subjective signs of palpitations, lightheaded, dizzy

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34
Q

Local anesthetic-induced symptoms of the test dose include: (3)

A

tinnitus, funny taste, dizzy

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35
Q

Intrathecal test dose s/s include: (4)

A

lower extremity warmth and heaviness, inability to straight-leg raise, hypotension, difficulty breathing

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36
Q

T/F Patient is confined to bed usually with a regular epidural

A

TRUE

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37
Q

Can’t use the epidural post delivery for repairs of the perineum due to tears T/F

A

FALSE
you CAN

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38
Q

Regular epidurals can be converted for Cesarean Section T/F

A

TRUE

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39
Q

Regular epidurals consist of what medications?

A

Local anesthetic with /without Opioid

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40
Q

______ has controversial effects on labor progression

A

regular epidurals

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41
Q

Possible lack of motor movement is characteristic of _____ epidurals

A

regular

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42
Q

Rapid and reliable analgesia, minimal motor blockade is characteristic of which neuraxial technique?

A

Combined Spinal-Epidural

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43
Q

How does the Combined Spinal-Epidural procedure compare to the epidural procedure?

A

Same procedure as Epidural, before the catheter is threaded a spinal needle is placed through the Tuohy needle until it enters the subarachnoid space, inject narcotic with/without local anesthetic, remove spinal needle and thread the epidural catheter

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44
Q

What should you watch for with a combined spinal-epidural?

A

profound hypotension and/or fetal bradycardia secondary to maternal decrease in catecholamine level and opioid use

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45
Q

______ can provide analgesia up to 120 minutes

A

combined spinal-epidural

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46
Q

After catheter placement for a combined spinal-epidural, position is confirmed by ______

A

negative aspiration of CSF and blood

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47
Q

There is a high chance of threading the epidural catheter into the dural puncture when doing a combined spinal-epidural T/F

A

FALSE
there is a LOW chance

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48
Q

What decreases the chance of getting into the subarachnoid space from dural puncture when doing a combined spinal-epidural?

A

Careful titration of epidural meds

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49
Q

What are the meds and doses for combined spinal-epidural?

A

Marcaine 2.5 mg with 20 mcq of fentanyl
Ropivacaine .1% with 2mcq/cc Fentanyl solution 3-4 cc’s

50
Q

Neuraxial Opioids Table

A
51
Q

What are the differences between an intentional dural puncture and an unintentional dural puncture?

A
52
Q

Cervical Spinal Nerves and Area They Serve (7)

A

C2:lower jaw, back of the head
C3:upper neck, back of the head
C4:lower neck, upper shoulders
C5:area of the collarbones, upper shoulders
C6:shoulders, outside of arm, thumb
C7:upper back, back of arm, pointer and middle finger
C8:upper back, inside of arm, ring and little finger

53
Q

Thoracic Spinal Nerves and Area They Serve (12)

A

T1:upper chest and back, armpit, front of arm
T2:upper chest and back
T3:upper chest and back
T4:upper chest (area of nipples) and back
T5:mid-chest and back
T6:mid-chest and back
T7:mid-chest and back
T8:upper abdomen and mid-back
T9:upper abdomen and mid-back
T10:abdomen (area of belly button) and mid-back
T11:abdomen and mid-back
T12:lower abdomen and mid-back

54
Q

Lumbar Spinal Nerves and Area They Serve (5)

A

L1:lower back, hips, groin
L2:lower back, front and inside of thigh
L3:lower back, front and inside of thigh
L4:lower back, front of thigh and calf, area of knee, inside of ankle
L5:lower back, front and outside of calf, top and bottom of foot, first four toes

55
Q

Sacral Spinal Nerves and Area They Serve (5)

A

S1:lower back, back of thigh, back and inside of calf, last toe
S2:buttocks, genitals, back of thigh and calf
S3:buttocks, genitals
S4:buttocks
S5:buttocks

56
Q

Coccygeal spinal nerves serve what areas? (2)

A

buttocks, area of tailbone

57
Q

Levels of Principal Dermatomes

A
58
Q

_____ is probably most common problem a/w epidurals

A

hypotension

59
Q

_____ and _______ are physiologic responses/complications a/w Sympathetic block?

A

peripheral vasodilation and increased venous capacitance

60
Q

Hypotension is defined by ______

A

BP less than 100 mm Hg or 20-30% systolic baseline decrease

61
Q

What is included in the treatment for hypotension a/w epidural?

A

LUD!!! Vasopressors and Fluids

62
Q

Supine Hypotensive Syndrome (Aortocaval Compression Syndrome) is a physiologic response/complication a/w?

A

epidural anesthesia

63
Q

What is the patho of epidural related maternal bradycardia? How would you treat it?

A
64
Q

What is the patho of epidural related N/V? How would you treat it?

A
65
Q

What can possibly happen with an epidural? (9)

A

Inadequate block/Failed block (One sided, sacral sparing)
Systemic Toxicity
Dural puncture
High Block
Prolonged/Significant Motor blockade
Back pain
Pruritus (Benadryl/Nubain)
Shivering
Subdural block (between the dura and arachnoid)

66
Q

A subdural block is between the ____ and _____

A

dura and arachnoid

67
Q

How would you treat pruritis a/w an epidural?

A

Benadryl/Nubain

68
Q

Placental blood flow decreases enough, you have ______

A

fetal bradycardia

69
Q

T/F Fetal bradycardia is a possibility of a 20% decrease in circulating epinephrine after labor analgesia initiated (epidural and CSE)

A

FALSE
50%

70
Q

Pain relief can also cause a decrease in ____, with increase in ______ and _______

A

BP
norepinephrine levels and uterine artery vasoconstriction

71
Q

decreased placental blood flow and fetal bradycardia can be caused by pain relief T/F

A

TRUE

72
Q

Treatment of Fetal Bradycardia

A

UTERINE DISPLACEMENT
O2 via facemask to increase fetal levels of O2
Treat hypotension quickly (ephedrine Vs Neo)
Turn off Pitocin
Fetal scalp stimulation
Change maternal position
Tocolytics (relaxes the uterus)

73
Q

What tocolytics are used to treat fetal bradycardia? What doses?

A

Terbutaline 0.25 mg subcutaneously (tachycardia)
Nitro SL sprays (2-3 sprays) or 100-200 mcq IV to relax the uterus (more if needed)

74
Q

O2 via facemask should be a part of the treatment of fetal bradycardia for what purpose?

A

to increase fetal levels of O2

75
Q

If there is fetal bradycardia you should turn off the Pitocin T/F

A

TRUE

76
Q

How do tocolytics affect the uterus?

A

relaxes the uterus

77
Q

2-Chloroprocaine 3% max dose =

A

800-1000 mg

78
Q

Which common LA is good for STAT C-sections or repair dosing post vaginal delivery?

A

2-Chloroprocaine 3%

79
Q

2-Chloroprocaine 3%

A
80
Q

Lidocaine 1%-2%

A
81
Q

Which common LA antagonizes opioid receptors (mu and kappa) and reduces efficacy?

A

2-Chloroprocaine 3%

82
Q

_____ is an ester, very rapid (3-5 mins) and lasts about 30 mins

A

2-Chloroprocaine 3%

83
Q

What is the onset of lidocaine?

A

10-15 mins

84
Q

Lidocaine 1%-2% max dose =

A

5-7 mg/kg

85
Q

Lidocaine lasts how long?

A

90-180 mins

86
Q

Lidocaine ___% with epi is used for test dose

A

1.5

87
Q

Lidocaine ___% with epi is used for cesarean

A

2

88
Q

___% to ____% Lidocaine is used for supplemental dosing for pre-existing epidurals

A

1-2

89
Q

Is lidocaine usually used as a continuous infusion for epidurals?

A

no

90
Q

Ropivacaine .1%-.5% max dose =

A

2mg/kg

91
Q

Ropivacaine .1%-.5%

A
92
Q

Bupivacaine .0625-.5% max dose =

A

1.5-3 mg/kg

93
Q

Bupivacaine .0625-.5%

A
94
Q

You get a greater sensory than motor block with which LA?

A

Ropivacaine

95
Q

T/F Ropivacaine has cardiotoxic potential

A

FALSE
Bupivacaine!!

96
Q

Which LA is highly protein bound? Is it good or bad to be highly protein bound?

A

Bupivacaine
BAD —-> death

97
Q

Can use ____ % Ropivacaine for break through pain or as an infusion

A

.2

98
Q

Can use .5% Ropivacaine for C-sections BUT _______

A

Patient may be able to move their legs more than with bupivacaine, lidocaine or chloroprocaine

99
Q

Bupivacaine onset

A

slower onset at 15-20 mins

100
Q

Bupivacaine lasts How long?

A

180-300 mins

101
Q

Ropivacaine lasts up to ____

A

180 mins

102
Q

Magnitude of systemic toxicity depends on:

A
103
Q

S/S of Systemic Toxicity

A
104
Q

Systemic Toxicity Treatment

A
105
Q

The lipid protocol is treatment with _____

A

Intralipid 20% solution

106
Q

Continue CPR throughout the lipid use, recovery from local induced arrest may take ______!

A

> 1 hour

107
Q

Lipid Protocol Chart

A
108
Q

Which epidural opiod has less resp depression with rapid onset and short duration?

A

fentanyl/Sufenta

109
Q

Fentanyl/Sufenta

A
110
Q

Morphine (Duramorph)

A
111
Q

Potential adverse effects a/w Morphine (Duramorph) include:

A

resp depression (may be 6-8 hrs after injection)
itching
urinary retention

112
Q

Which epidural opiod requires pulse oximetry up to 24 hrs after injection?

A

Morphine (Duramorph)

113
Q

Morphine (Duramorph) should be given in what doses?

A

2-5 mg

114
Q

Morphine (Duramorph) onset and duration

A

onset up to 45 mins and can last up to 24 hrs, slow to take effect

115
Q

What are the 3 spinal opiods/adjuncts and their doses?

A
116
Q

What is the most common SE of epidural and intrathecal opioids?

A

pruritis

117
Q

How do you treat pruritis a/w opiods?

A

Nubain (2.5-5mg), Narcan (20-80mcg)

118
Q

prolonged hypotension can cause: (3)

A

decreased uteroplacental perfusion
fetal hypoxia
acidosis

119
Q

Placental circulation is autoregulated T/F

A

FALSE
it is NOT

120
Q

Hypotension definition

A

20-30% decrease in systolic BP or systolic less than 100 mm Hg

121
Q

Prevention/Treatment for hypotension includes: (3)

A

WEDGE
fluids
vasopressor

ob exam 1 (13 decks)

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