Module 8: Part 2 Flashcards
24-46
30-40% pregnant women have a fasting gastric volume of ___ ml and ___ acidity
volume > 25 ml
gastric fluid acidity < 2.5
Hi, Mendelson Syndrome, how are ya?
Bicitra
when to give?
how much to give?
why?
give 30 ml at least 20 min prior to induction
Non-particulate antacid; buffers gastric fluid and raise pH
H2 antagonist (Pepcid)
when to give?
moA?
within 30 minutes of induction
(max effect in 60-90 min)
prevents histamines potentiation of acid production
T/F
Pepcid (20 mg) inhibits gastric acid pH
False
inhibits gastric acid secretion
Reglan
dose
moA
10 mg
increases LES & reduces gastric volume by increasing peristalsis
Aspiration Prophylaxis
medication options
- Non-particulate antacid (Bicitra 30 ml)
- H-2 antagonist (Pepcid 20 mg)
- Reglan (10 mg)
- Proton-Pump inhibitors
- Zofran
Decreases in Maternal mortality from pulmonary aspiration are due to:
(5)
- Increased use of NA (most important factor in decline)
- Reglan, Pepcid and Bicitra, PPI’s
- RSI and general anesthesia
- Training, Communication
- NPO policies
Nerve Lesions can be located…
Central
&
Peripheral
Nerve Lesions
Central vs. Peripheral
Central:
* Mostly bilateral
* weakness or paralysis from the site of the lesion distally
* autonomic dysfunction
* possible upper motor neuron signs (spasticity, bowel/bladder dysfxn)
Peripheral:
* Usually unilateral
* Weakness or paralysis limited to a single muscle or muscle group that the peripheral nerve innervates
(Central/Peripheral) Nerve Lesions are often a/w as spasticity and bowel/bladder dysfunction.
Central
Central:
* Mostly bilateral
* weakness or paralysis from the site of the lesion distally
* autonomic dysfunction
* possible upper motor neuron signs (spasticity, bowel/bladder dysfxn)
Obstetric injuries include compression & palsies of….
compression: lumbosacral trunk
palsies: obturator, femoral, lateral femoral cutaneous, sciatic and peroneal nerves
Peripheral Nerve Palsies
ocurrence
0.6 to 92 per 10,000 reported incidence
(Central/Peripheral) Nerve Palsies usually have obstetric causes instead of neuraxial
peripheral
Peripheral Nerve Palsies often occur from …
compression in the pelvis by the fetal head
Distal compression (positioning) is a/w (Central/Peripheral) Nerve Palsies
peripheral
Signs of Peripheral Nerve Palsies are often overlooked if…
using neuraxial
Peripheral Nerve Palsies
Risk factors
- prolonged second stage of labor
- difficult instrumental delivery
- nulliparity
- prolonged lithotomy position
Neurologic Complications in OB
Anesthesia vs. Childbirth
Neurologic injuries of childbirth
Risk factors
- Prolonged 2nd stage
- Nulliparity
- Epidural (stretch and compression injuries masked)
- Positioning/ time in lithotomy
- Operative delivery
- Malpresentation, occiput posterior, fetal macrosomia
About 1% of neurlogical injuries is d/t
childbirth
Neurologic injuries of childbirth
how long do they last?
does it resolve?
- Median duration 6-8 weeks
- Symptoms resolve or improve in most
Intrinsic Birth Nerve Injuries
(2)
Lateral femoral cutaneous
(MOST common)
Femoral
(second)
T/F
Femoral nerve injuries are the most common nerve injury d/t intrinsic birth.
False
Lateral femoral cutaneous
(Intrinsic birth injuries)
Lateral femoral cutaneous
vs
Femoral
Lateral femoral cutaneous
* compression under inguinal ligament
* prolonged hip flexion or pressure at waist
* sensory deficit on anterolateral aspect of thigh
* purely sensory
Femoral
* C/S: retractor compression against pelvic wall
* partial hip flexion
* weak knee extension
* diminished patellar reflex
* hyperesthesia: anterior thigh and medial calf
Which nerve injury is purely sensory?
Lateral femoral cutaneous
All are true of Lateral femoral cutaneous nerve injury EXCEPT:
A) most common intrinsic birth nerve injury
B) purely sensory
C) can be caused by retractor compression against pelvic wall
D) caused by compression under inguinal ligament
E) prolonged hip flexion or pressure at waist
C) can be caused by retractor compression against pelvic wall
this applies to femoral nerve injury
T/F
Bicitra only works if you take all 30 ml.
True
suck it up, buttercup
Peripheral nerve injuries other than Lateral femoral cutaneous and Femoral are more r/t…
- fetal head
- forceps
- retractors
Lumbosacral plexus injury
75% unilateral
25% bilateral
- large fetus
- malpresentation
- small pelvis
Mom has a small pelvis. Wha nerve injury is she at risk for?
Lumbosacral plexus injury
Peripheral nerve injuries other than Lateral femoral cutaneous and Femoral
- Lumbosacral plexus
- Sciatic
- Peroneal
- Obturator
Mechanisms by which bladder function may be disturbed
SATA
Which can contribute to urinary incontinence and retention?
A) subarachnoid neurotoxicity
B) damage to lateral pelvis
C) uterine hypertrophy
D) cauda quina syndrome
E) trauma to conus
A) subarachnoid neurotoxicity
D) cauda quina syndrome
E) trauma to conus
damage to pelvic FLOOR
postpartum ATONY
Neurologic Sequelae of Dural Puncture
(2)
- Cranial nerve palsy (major CSF loss d/t dural puncture with a large needle)
- Cranial subdural hematoma (↓ CSF pressure can rupture bridge meningeal veins)
Cranial nerve palsy
major CSF loss if dural puncture with a large needle
* Cranial nerve VI, VII and VIII most common
* Abducens (VI) most vulnerable
* prompt epidural patch
* possible delayed recovery
* If cranial nerve VIII, tinnitus may become permanent
Cranial subdural hematoma
Decreased CSF pressure can rupture bridge meningeal veins
* use blood patch
* if headache persists + altered consciousness, seizures or focal issues…. Immediate MRI and possible surgery
T/F
Blood patch is used for Cranial subdural hematoma but not Cranial nerve palsy.
False
must use for both!
Mechanism by which lesions of the central nervous system may arise in parturients
Epidural Hematoma must be taken to surgery within..
6 hours
If paresthesia with insertion of the needle for SAB/Epidural
….
Stop advancing and redirect the needle once paresthesia goes away
Epidural cath can injure a nerve root if..
too rigid or inserted too far
Spina bifida occulta
Imaging is preferred (practitioner dependent)
insert needle remote from site of malformation seen on imaging
Patients with _____ are athigher risk of post dural puncture headache
Spina bifida occulta
T/F
Neuraxial anesthesia is contraindicated in Spina bifida occulta
False
not if its occulta
You’re doing a SAB. When injecting the local anesthetic, the patient complaints of pain. What can happen?
SAB Insertion Trauma
T/F
CSF leak can cause arachnoiditis.
False
wrong injection or formulation
Epidural Hematoma
-Blood collects in epidural space
-Rare in OB
Signs/symptoms:
* Acute back pain and radicular pain
* LE numbness and weakness
* Urinary and bowel dysfunction
Epidural Hematoma
Risk factors
- Difficult epidural
- coagulopathy
- spinal deformity
- spinal tumor
Epidural Hematoma
what do to if suspected
- Immediate MRI & neuro consult
- Minimize time to decompression
- If >6 hours since s/s & diagnosis, often don’t recover
Epidural abscess
- 4-10 days postpartum
- Severe Backache & local tenderness
- Fever, headache, neck stiffness
- Staph (most common)
- WBC and ESR increased
- Often mistaken for PDPH
In contrast to epidural hematoma, symptoms of epidural abscess are more ___
insidious
develops slowly without noticing
Often mistaken for PDPH
Epidural abscess
Epidural abscess
intervention
- Prompt MRI
- Antibiotics, needle drainage
- Surgical decompression
Epidural Abcess vs Meningitis
usual causative organism
Epidural Abcess: Staphylococcus aureus
Meningitis: Streptococcus salivarius
Procedures to Decrease the Risk for Infection after Neuraxial Anesthesia
Not wearing a mask during NA can cause
meningitis
T/F
Cauda Equina Syndrome and transient neurlogical syndrome are examples of a chemical injury.
True
Cauda Equina Syndrome
what is it?
S/S?
- Pressure or swelling of the lumbar nerves
- Hematoma
- Severe low back pain, motor weakness, sensory loss, bowel and bladder dysfunction
- Needs immediate treatment
Cauda Equina Syndrome
caused by…
Intrathecal injection of hyperbaric 5% lidocaine and sometimes other locals
Transient neurologic syndrome
what is it?
S/S?
Pain: buttocks, back, thighs
Lithotomy position
Transient presentation
Transient neurologic syndrome
- Follows spinal and usually the use of lidocaine
- Concentration, additives, and preservatives of LA
- More with Lidocaine and mepivaine vs prilocaine and bupi
Which LA is a/w a higher rate of Transient neurologic syndrome?
A) Prilocaine
B) Bupivicaine
C) Chloroprocaine
D) Tetracaine
E) Lidocaine
E) Lidocaine
- Follows spinal and usually the use of lidocaine
- More with Lidocaine and mepivaine vs prilocaine and bupi
Arachnoiditis
Neurologic condition
-pain, stinging or burning in the back, perineum, legs, arms and feet
-worse case: paraplegia
Arachnoiditis
-causes
-treatment
Injection of dyes, iodine
Exposure to chemicals that do damage to the arachnoid and meninges
Treatment: MRI, Pain meds, Steroids?
Adhesive arachnoiditis
chemical origin from intrathecal injection of medications with preservatives, iodine
We must deliver, If CPR is unsuccessful after this long
4 minutes
Direct trauma and injury
- Single root neuropathy
- Radicular injuries often with pain or paresthesia
- Damage to conus medullaris from SAB/CSE
- Neurotoxicity from wrong drug or high concentration
- Lidocaine 5%
T/F
0.75% Bupivicaine is the LA most often a/w direct nerve trauma and injury.
False
Lidocaine 5%
pinching of nerve
Radiculopathy
Nerve injury prevention
- Stop advancing needle if pain
- Inject or place catheter if pain resolves
- Remove & start again if it doesn’t resolve
- use low lumbar site for SAB
- Double check drugs & dose (EPI ?)
- Aseptic technique
Assessment of neurologic injury
- Full details of labor & delivery course
- Assess neurologic deficits & pain
- Onset, progression
- Sensory or motor?
- Consider neuro consult
- PT consult
- Differential diagnosis (birth injury or neuraxial)
When assessing neurologic injury, what’s the differential diagnosis?
birth injury or neuraxial
Horner’s Syndrome can be seen after…
epidural insertion, brachial plexus block
usually due to the spread of local anesthesia
Stellate blocks; converting labor→c/s epi-d
bc high dose lido
T/F
Horner’s Syndrome is benign and short-lived.
True
Usually self-limiting
Horner’s Syndrome
most common presentation
Unilateral ptosis with miosis
Horner’s Syndrome
s/s
- Unilateral ptosis w/ miosis (most common)
- Anhidrosis
- enophthalmos
- High sympathetic block but pt is breathing
Differential Diagnosis of Postpartum Headache
Review table 30-1
its huge
- Tension headache
- Migraine
- Musculoskeletal
- Preeclampsia/eclampsia
- Posterior reversible (leuko)encephalopathy syndrome (PRES)
- Stroke
- Subdural hematoma
- Carotid artery dissection
- Cerebral venous and sinus thrombosis
- Brain tumor
- Idiopathic intracranial HTN (pseudotumor cerebri/benign)
- Spontaneous intracranial hypoTN
- Pneumocephalus
- Meningitis
- Sinusitis
- Caffeine withdrawal
- Lactation headache
- Ondansetron headache
- Post–dural puncture headache
Postpartum headaches occur during the first __ weeks after delivery and manifest as …
6
cephalic, neck or shoulder pain
Differential Diagnosis of Postpartum Headache
just what the ppt mentioned
- Migraine
- tension
- musculoskeletal
- pre-E
- subarachnoid hemorrhage
- brain tumor
- subdural hemorrhage
- meningitis
- caffeine withdrawal
- PDPH
Postpartum Headache
primary vs. secondary
Primary headaches are 20 times more common than secondary in the first week postpartum
most common postpartum complication of neuraxial anesthesia
Post-Dural puncture headaches (PDPH)
