Module 8: Part 1

Question 1

3 Major Safety Initiatives Addressed in Anesthesia

Answer 1

LAST

Greater used of neuraxial for cesareans

Protocols and devices to improve general anesthesia

Question 2

communication failures/reasons for malpractice claims

Answer 2

Lack of informed consent
Poor patient rapport
Language barriers
Inadequate discharge instructions (PDPH)

Question 3

patients have the right to be told…

Answer 3

what to expect and to determine what will be done with their bodies

Question 4

Patient can make an informed consent only after (3)

Answer 4

Discussion about diagnosis and indications for procedure
Risks, benefits and alternatives
Opportunity to ask questions/answers

Question 5

special considerations for decision making in OB anesthesia (5)

Answer 5

Patient who is in pain
Patient who has received sedatives
Patient with a birth plan
Emergency procedures
Cultural considerations

Question 6

2 most common injuries in obstetric anesthesia claims in ASA Closed-Claims database

Answer 6

Maternal nerve injury (19%) and neonatal brain damage (16%)

Question 7

3rd and 4th most common injuries in OB anesthesia claims

Answer 7

maternal death (15%) and headaches (11%)

1) Maternal nerve injury (19%)
2) neonatal brain damage (16%)

Question 8

More maternal nerve damage claims with ____________ (29%) than ____________ delivery (13%)

Answer 8

More maternal nerve damage claims with vaginal (29%) than cesarean delivery (13%)

Question 9

Neonatal brain damage is higher in ____________ delivery

Answer 9

cesarean 21% vs vaginal 13%

Question 10

Block-related events in Obstetric Claims (4)

Answer 10

High spinal/epidural (6%)
Dural puncture headache (6%)
Inadequate analgesia (5%)
Retained catheter (4%)

Question 11

more than 1/2 of maternal hemorrhage is associated with

Answer 11

abnormal placentation

Question 12

what is the primary cause of sentinel events?

Answer 12

Poor communication among health care workers

Question 13

risk factors for pulmonary aspiration (7)

Answer 13

Full stomach
pregnancy
bowel obstruction
GERD
Obesity
GI disorders
Neurologic conditions

Question 14

difficult or failed intubation in pregnancy

Answer 14

up to x11 greater

Question 15

most cases of pulmonary aspiration occur

Answer 15

during elective procedures

Question 16

what promotes aspiration? (3)

Answer 16

• Increased gastric pressure
• decreased LES tone
• blunted protective airway reflexes

Question 17

Functions as an anti-reflux barrier

Answer 17

lower esophageal sphincter

Question 18

LES pressure

Answer 18

20 cm H20

Question 19

what is prevented by the LES

Answer 19

Passive reflux and regurgitation of gastric contents is prevented by LES

Question 20

ASA and ACOG NPO recommendations allow for

Answer 20

clear liquids in uncomplicated labor but avoidance of solid food

Question 21

Morbidity and mortality of aspiration depends on (3)

Answer 21

Chemical nature of the aspirate
Physical nature of the aspirate
Volume of the aspirate

Question 22

Aspirates with a pH < 2.5 cause

Answer 22

a granulocytic reaction that continues beyond the acute phase

Question 23

aspiration pneumonitis or Mendelson’s syndrome

Answer 23

acidity of gastric contents results in chemical burn to tracheobronchial tree and alveoli

Question 24

chemical pneumonitis usually occurs when (2)

Answer 24

pH <2.5 and volume greater than 25 ml (0.4 ml/kg)

Question 25

most common site of aspiration

Answer 25

R. Lower Lobe

Question 26

Large particle aspiration causes

Answer 26

atelectasis from obstructed large airways

Question 27

chemical pneumonitis is a parenchymal reaction with injury to

Answer 27

alveolar epithelium, edema

Question 28

Aspiration of nonparticulate, neutral liquid leads to

Answer 28

minimal damage

Question 29

chemical pneumonitis onset

Answer 29

Acute onset or abrupt development of symptoms within minutes (bronchospasm, decreases in PaO2 with increased shunting)

Question 30

potential signs and symptoms of pneumonitis

Answer 30

will breath hold then have tachypnea, tachycardia, slight respiratory acidosis

Question 31

significant aspiration S&S

Answer 31

hypoxia caused by greater shunting and usually bronchospasm

Question 32

general pneumonitis S&S

Answer 32

• Bronchial obstruction
• pulmonary edema
• reduced compliance
• shunting → hypoxemia
• VQ mismatch

Question 33

bronchospasm algorithm in intubated patient

Answer 33

Question 34

Abnormal chest xray can be seen when with pneumonitis?

Answer 34

12-24 hrs after clinical signs

Question 35

Berlin definition of ARDS (4)

Answer 35

Clinical: within 1 week of known clinical insult

Chest imaging: bilateral opacities not explained by effusions

Biochemical: PaO2/FIO2 ratio less than 300 with CPAP or PEEP > 5 cm H2O

Origin of pulmonary edema: not explained by cardiac failure or fluid overload

Question 36

initial management of aspiration pneumonitis

Answer 36

1. T-berg
2. Suction
3. ETT
4. soft suction primary bronchi
5. Fiberoptic bronch (eval extent & prescence of solids)
6. remove liquid contents
7. Rigid bronch if large particles are causing obstruction

LACK of evidence: corticosteroids, routine prophylactic abx, lung lavage w/ saline & bicarb

Question 37

treatment of hypoxia associated with aspiration

Answer 37

CPAP
PEEP
Mechanical ventilation
Conservative fluid strategy

Question 38

CPAP in treatment of hypoxia

Answer 38

used in patients breathing spontaneously

Question 39

function of PEEP (with mechanical ventilation in patients with hypoxia)

Answer 39

• restores FRC
• reduces pulmonary shunting
• helps reverse hypoxemia

Question 40

mechanical ventilation in patients with hypoxia

Answer 40

restores FRC, reduces pulmonary shunting, and helps reverse hypoxemia

Question 41

Mechanical Ventilation
(key points in managing ARDS)

Answer 41

• Limit plateau pressure to 30 cm H20
• Use lowest effective Vt (6 ml/kg)
• PEEP (titrated) in moderate to severe ARDS
• higher PEEP in moderate-severe ARDS