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Clinical prep > OB > Flashcards

OB Flashcards

1
Q

Who does the clear liquid = no limits NOT apply to?

A

on magnesium or insulin infusion, scheduled for surgery or admitted for observation….complicated patients = strict 8 hr NPO

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2
Q

NPO guidelines for elective or non schedules, non- urgent surgery

A

8 hrs - solids
6 hrs- soft
2 hrs- clear liquids

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3
Q

Lower limit for platelets for Epidural/ CSE

A

70,000

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4
Q

Lower limit for platelets for SAB

A

50,000

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5
Q

Platelets hsould be checked with preeclampsia or thrombocytopenia every ______

A

12 hrs

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6
Q

Epidural catheters should be removed immediately if EBL is_____

A

<1500 mls…..if creater order a CBC and plat count.

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7
Q

Epidural catheter should be removed if plat ____

A

equal or greater than 70,000

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8
Q

Aspiration prophylaxis at what gestation?

A

16 weeks or more = full stomachs

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9
Q

Aspiration prophylaxis medications and dose

A

10 mg IV metroclopramide (inject into IV bag (don’t give IV push -> EPS)
20 ml of bicitra PO.
famotidine 20 mg

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10
Q

ALL OB intubations are……

A

RSI

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11
Q

What preops are not routinely given because of the risk of fetal depression

A

midazolam and fent …..try bendryl instead

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12
Q

the decision to use as CSE is based on

A

prior C/S >=2
High BMI,
possible difficult airway
Other factors could prolong the case past 1.5-2 hrs.

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13
Q

What is the min or max cervical dilation for a patient to receive labor analgesia

A

there is none

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14
Q

What is in a test dose

A

3 ml of lidocaine 1.5 % w/ 1: 200,000 epi

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15
Q

what is a negative test dose

A

heart rate increase no greter than 20 BPM avove baseline , no signs of systemic effect within 2 min and no loss of ability to raise or lower extremities against gravity within 4 min after injection

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16
Q

Preloading / coloding dose

A

500-1000 ml of LR during neuraxial placement

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17
Q

what is the programmed intermittenet bolus concentration for epidural

A

0.1% ropic with 2 mcg/ml fent

first bump dose of 9 MLS is delivered 50 minutes after the initiation with programed 9 ml doses q 50 min there after.

PCEA bolus is 10 ml with q 10 min lockout and a max hourly allowed 55ml/hr

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18
Q

initial epidural bolus and how is it made?

A

0.1% rop 5-10 ml with 100 mcg of fent as the initial bolus mixed from 5 ml of 0.2 % and 5 ml of preservative free saline.

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19
Q

Do not inject more than ____ mls of LA solution at one time

A

5 mls ….use of higher concetrations (0..2%) may cause hypotension.

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20
Q

when to use a dural puncture epidural

A

anticipation/ proven difficult placment or during replacement of poorly functioning epidural catheter.

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21
Q

CSE initiation dose

A

manual injection of 1.6-2 mg ropivacaine (0.8-1 ml of rop 0.2%) intrathecally or epidural fent is unnecessary. maintenance is the same as the epidural analgesia after a negative test dose.

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22
Q

continuous spinal dose and when its does

A

inadvertent dural puncture in conditions when routine epdirual or CSE cannot provide reliable analgesia. no initiation dose, maintenance is provided with normal infusion in continuous mode at 2 ml / hr with PCEA bolus of 1 ml/20 min. max hourly is 7 ml. bupiv 0.5% and place in bedside box to be used in the event of an emergency cesarean delivery.

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23
Q

Patient positioning after epidural

A

lay on their back after epidural -> decrease venous return. w/ isobaric solution it is not necessary to place on the back to achieve a bilateral block.

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24
Q

treatment for inadequate block width

A

Administer a provider bolus with a syringe of ropivacaine 0.1% or deliver a provider bolus from the pump and increase pump delivery volume by 20%

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25
Q

treatment for inadequate block density

A

sufficient block level to ice but pain exists

administer a manual bolus of 5 ml of rop 0.2%. consider replacing the epidural father if no relief.

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26
Q

treatment for one sided block

A

withdraw the catheter by 1 cm and adminster 10 ml of rop 0.1% with 2 mcg /ml fent. consider replacing the epidrual catheter if no relief.

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27
Q

what are surgical concentrations of LA

A

bupiv 0.5%, lidocaine 2% for labor analgesia.

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28
Q

forceps vaginal delivery or perineal repair dose

A

chloroprocaine 3% as needed up to 10 ml consider with sodium bicarbonate, based on the patients pain level and ability to sense and push

for perineal repair “surgical” concentrations of LA agents and neuraxial narcotics can be used as needed.

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29
Q

SAB dosing

A

1.4-1.8 ml 0.75% bup w/ 20 mcg fent plus duramorph 0.1 mg.

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30
Q

place SAB then _____

A

place supine with LUD q 1 min NIBP and start phenylephrine infusion upon injection and return supine LUD.

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31
Q

Dermatome level for C/S

A

T2-T4. block shouldnt progress high enough to affect the C8 dermatome.
phonating = breathing. hard to swallow -> raise HOB.

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32
Q

antibiotic prior to skin incision

A

cefazolin 2 grams

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33
Q

Oxytocin mixture for C/S

A

500 ml/30 units of oxytocin ….all patients receive 60 units following delivery divided into 1 L total.

first bag infuses at 500 ml/hr
second bag at 125 ml/hr.

burp all IV bags since pressure bags are often used in OB to expedite uterine contractions

wait until after placental delivery before giving pitocine.

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34
Q

meds to give after deliver / mother - baby bonding

A

midazolam and fentanyl

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35
Q

What meds are given IM in OB anesthesia

A

Prostin (hemabate/carbaprost) and methergine given IM in the deltoid!!

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36
Q

who is at risk for uterine atony post - delivery

A

prolonged labor or a long induction with pitocin and mag sulfate for pregnancy-induced hypertension

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37
Q

frequency between giving uterotonic agents

A

frequency of admin for each drug is 15 minutes but in the case of severe atony it can be alternate drugs that shorted time of 7.5 min.

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38
Q

who do you not remove the epidural catheter at the end of the case on?

A

in coagulopathic patients,&raquo_space;> EBL than normal, possible return to OR for bleeding, frequency flier wound debridement, difficult CSE placement. if left notify the high risk epidural manager.

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39
Q

what is considered an unreliable neuraxial analgesia

A

two or more provider boluses (top - ups) should be replaced before a cesarean delivery is called

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40
Q

procedure for C section with labor epidural

A

discontinue epidural infusion asap and waste whats left.
assess block level

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41
Q

redosing for antiemetics

A

bicitra q 30 min
regalan q 6 hrs

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42
Q

ASAP C/s with labor epidural dosing

A

2% lidocaine with epi and added sodium bicarb (10:1), plus 100 mcg of fent if none given epidrually over past hr. usually 10 ml to start with additional 5 ml doses as needed with level assessment.

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43
Q

STAT c/s with labor epidural dose

A

20 ml 3% 2-chloroprocaine to achieve operative analgesia quickly. consider adding 1 meq of sodium bicarb per 10 ml of 3% chloroprocaine. assess levels upon arrival to the or. also admin 100 mcg epidrual fent if none had been given over the past hour. subsequent dosing may be admin if necessary in 5 ml increments. 30 min duration of action requires subsequent dosing with lidocaine to maintain surgical analgesia.

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44
Q

to convert to intrathecal analgesia to cesarean anesthesia dose

A

1 ml of 0.5% bupiv with incremental dosing of 0.5 ml. 20 mcg of fent can be added aswell.

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45
Q

maintenance for c/s under General

A

volatile +/- nitrous, fent, midazolam , ketamine

high levels increase uterine atony and hemorrhage

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46
Q

what blocks can be performed for cesarean under GETA without neuraxial

A

TAP max 20 ml of liposomol bupiv (exxperel, 266 mg) and 20 ml of 0.25% bupiv (total 40 ml) 20 ml each side .

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47
Q

Bilateral tubal ligation post partum SAB doses

A

0.75% 1.2-1.8 ml with 20 mcg fent. tubal ligations are less than an hour.

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48
Q

SAB for D&C dose

A

0.75% 1.2-1.8 ml with 20 mcg fent, usually a smaller dose because the case is shorter

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49
Q

pitocin dose for D&C

A

20-30 units of pitocin are injected into IV bag for uterine contraction to assist with hemostasis.

anxiolytic if upset over loss of pregnancy

check hemaque if concerned.

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50
Q

steps to reduce PDPH

A

injection of csf from syringe back into subarachnoid space through needle, insertion of catheter subarachnoid, administration of continuous intrathecal labor analgesia, injection of preservative free NS through catheter before removal. or leaving the intrathecal catheter in-situ for 12-24 hrs.

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51
Q

PDPH diagnosis

A

HA is positional, occuring within 15 min of upright position and resolving within 15 min of supine position plus one of the following;

neck stiffness
tinnitus
hypercusia
photophobia
nausea

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52
Q

Gold standard for PDPH treatment

A

epidural blood patch

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53
Q

Epidural blood patch steps

A

pre-populated consult note, consent patient and arranged for transport to ECU/PACU

use a new aseptic venipuncture site for the blood draw and the space one level below the original entry side for EBP. inject 20 ml of fresh autologous blood,. lower volume is acceptable if the patient feels back discomfort or resolution of HA

place supine for 1-2 hrs or longer. instruct to avoid heavy lifting for 12 hrs. may return to the floor after 1-2 hrs.

REPEAT EBP CAN BE OFFERED IF SYPTOMS RECUR. CONSIDER IMAGING IF MORE THAN 2 ARE NEEDED. advise 100% O2 for 12 hr if imaging shows pneummocephalus.

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54
Q

what physiologic changes cause engorgement and hyperemia

A

increased progesterone, estrogen and relaxin

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55
Q

Rib changes in pregnancy

A

relaxin relaxes the ligaments of the ribcaage -> more horizontal positioning.

increase anterior - posterior diameter of the chest = more space for lungs.

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56
Q

lung volume changes in pregnancy

A

FRC is reduced
inc oxygen consumption -> hypoxemia w/ apnea.

frc is below closing capacity -> airway closure during tidal breathing

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57
Q

what hormone is a respiratory stimulant

A

progesterone -> inc mv by up to 50%.

moms PaCO2 falls and she develops resp alkalosis.

renal compensation eliminates bicarb and normalize blood pH.

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58
Q

Oxy hb dissocation curve changes with pregnancy

A

inc P50 (right shift) facilitates O2 transfer to fetus

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59
Q

how much co does the uterus receive and CO changes during labor

A

10%

uterine contraction causes autotransufion -> inc preload

1st stage if labor 20%
2nd stage of labor 50%
3rd stage of labor 80%

returns to preloabor 24-48 hrs
return to pre pregnancy - 2 weeks

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60
Q

progesterones effect on nitrous oxyide and angiotensin and ne

A

inc NO -> vasodilation -> inc SVR
increases RAAS / Dec response to angiotensin and NE

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61
Q

clotting changes with pregnancy

A

inc 1,7,8,9,10,12 -> hypercoagulable states
dec antithrombin (DVT risk)

inc fibrin breakdown. decrease factors 11 and 13 -> faster breakdown of clots —-> risk of consumption coagulopathy.

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62
Q

pregnancy changes to serum albumin and pseudocholinesterase

A

dec albumin -> inc free fraction of highly protein bound drugs

dec pseudocholinesterase -> no meaningful effect on succ metabolism

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63
Q

uterine blood flow and pheylephrine

A

not reduced. Using phenylephrine instead of ephedrine is associated with a higher fetal blood pH.

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64
Q

does uterine blood flow autoregulate

A

no. it is dependent on MAP, co and uterine vascular resistance.

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65
Q

uterine blood flow formula

A

uterine artery pressure - uterine venous pressure / uterine vascular resistance.

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66
Q

fick law of diffusion for drug transfer across the placenta

A

diffusion coefficine x surgace area x centraction gradient / membrane thickness

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67
Q

what drug characteristicks favor placental transfer

A

low molecular weight < 500 daltons
high lipid solubility
non ionized
non polar

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68
Q

what drugs have significant placental transfer

A

Local anesthetics (except chlorporcaine)
IV anesthetics
volatile anesthetics
opioids
benzos
atropine
beta blockers
magnesium

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69
Q

no placental transfer

A

nm blockers
glycopyrrolate
insulin
heparin

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70
Q

first stage of labor

A

begins with cervical dilation with regular uterine contractions and ends with full cervical dilation (10cm). divided into latent and active stage

pain begins in the lower uterine segments and the cervix. signals travel to the T10-L1 posterior roots

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71
Q

second stage of labor

A

full cervical dilation and ends with delivery of the newborn

adds in pain impulses from the vagina, perineum and pelvic floor

pain impulses travel from the perineum to the S2-S4 posterior nerve roots

neuaxial that provide T10 - L2 during the first stage must be extended to cover S2-S4 during the second stage for a total coverage of T10-S4

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72
Q

third stage of labor

A

egins with delivery of the newborn and ends with delivery of the placenta

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73
Q

NPO guidelines for laboring mothers

A

always a full stomach

healthy moms may drink a moderate amount of clear liquids throughout labor
eat solid food up to the point a neuraxial block is placed

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74
Q

pudendal nerve block covers what area

A

perineium S2-S4 pudendal nerve.
sharp and well localized

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75
Q

which local anesthetic reduces the efficacy of epidural morphine

A

2 chloroprocaine because it antagonizes mu and kappa receptors in the spinal cord.

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76
Q

side effects of neuraxial opioids

A

pruritis, n/v, sedation and resp depression

when administered alone include a lack of perineal relaxation and less analgesia compared to LA

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77
Q

normal fetal heart rate and variability

A

110-160

6-25 bpm = variability

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78
Q

what reduce variability

A

CNS depressants
hypoxemia
fetal sleep
acidosis
anencephaly
cardiac anomalies

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79
Q

Early decels mean….

A

head compression

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80
Q

Late decels mean….

A

uteroplacental insufficiency (maternal hypotension, hypovolemia, acidosis, preeclampsia

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81
Q

Variable decelerations means….

A

umbilical cord compression

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82
Q

How long does it take betamethasone to take effect and when does it peak

A

peaks in 48 hrs
takes effect in 18 hrs

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83
Q

Beta 2 agonists used as tocolytics

A

ritodrine
terbutaline

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84
Q

MOA of beta 2 agonsits as tocolytics

A

increase cAMP, in turn PKA turn off MLCK -> relaxes the uterus.
increase progesterone release, which contributes to additional myometrial relaxation

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85
Q

moa of magnesium sulfate as a tocolytic

A

calium antaonsits -> smm relaxation of the vasculature, airway and uterus. and hyperpoarizes membranes in excitable tissue -> sz prophylaxis and treats preeclampsia.

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86
Q

what is the first sign of mag toxicity

A

diminished of deep tendon reflexes

usually between 5-7 mg/dl with lethargy/ drowsiness, flushing, N/v

usually loose reflexes between 7-12 mg/dl

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87
Q

treatment for hypermagnesmia

A

supportive care
diuretics
IV calcium gluconate 1 g over 10 minutes (to antagonize mg)

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88
Q

CCB used as a tocolytic

A

nifedipine = first line
co - administer with mag can contribute to skm weakness

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89
Q

NO moa as a tocolytic

A

vasodilator and is essential in maintaining smm tone increases cgmp, turns off MLCK and relaxes uterine muscle.

rarely used due to hypotension

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90
Q

dose of methergine

A

0.2 mg IM

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91
Q

Where is oxytocin synthesized and stored/ released

A

paraventricular nuclei of the hypothalamus

stored and released in the posterior pit gland

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92
Q

side effects of oxytocin

A

water retention, hyponatremia, hypotension , reflex tachycardia, coronary vasoconstriction

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93
Q

metabolism of oxytocin

A

hepatic

94
Q

half-life of oxytocin

A

4-17 min

95
Q

routes of oxytocin administration

A

IV or intrauterine

96
Q

Methergine type of medication

A

Ergot alkaloid
uterotonics

97
Q

half life of methergine

A

2 hours

98
Q

Hemabate/ carboprost type of medication

A

prostaglandin F2

99
Q

Hemabate/ carboprost dose

A

250 mcg IM or intrauterine

100
Q

Side effects of hemabate/carboprost

A

n/v, diarrhea, hypotension, htn, bronchospasm

101
Q

normal amniotic fluid volume

A

700 mls

102
Q

what medications are given as prophylactic aspiration

A

sodium citrate 15-30 ml within 15-30 min of induction
h2 receptor antagonists (ranitidine) 1 hr before induction
Gastrokinetic agent (metolopramide) 1 hr before induction

103
Q

when is the best time for surgery in the pregnant patient

A

second trimester ; avoid teratogenicity and inc risk of preterm delivery that’s highest during the 3rd trimester

104
Q

when is organogenesis

A

day 13-60

105
Q

hyperventilation and the risk to the fetus

A

Maternal hypocapnia/metabolic alkalosis -> L shift in O2 curve -> dec O2 unloading to the fetus
redues placental blood flow -> risk of fetal asphyxia

maternal hypercapnia -> Co2 to fetus -> fetal acidosis/ myocardial depression

106
Q

why do we avoid nsaids

A

potentially close the ductus arteriosus

107
Q

what physiologic changes is preeclampsia associated with

A

increase proteinuria
increased thromboxane
increased vasoconstriction
decreased prostacyclin
enhanced protein aggregation

108
Q

what is the batsons plexus

A

a network of epidural veins that drain the spinal cord and the meninges. typically passes through the lateral and anterior regions of the epidural space

109
Q

What is the normal weight gain for a pregnant women and how is it divided up

A

12 kg ~ 1 lk / week

1 kg each to the uterus and amniotic fluid
4 kg to the fetal and placenta weight
4 kg to the new gat and protein stores
2 kg to blood volume increase

110
Q

when does blood volume increase occur and by what percent and what factors. when does it return to prepregnancy levels

A

8-32 weeks majority inc at week 24
30-35% increase
inc plasma and RBCs (Plasma > RBC)
6 weeks postpartum = return to prepreg

111
Q

EBV female pregnant vs non pregnant

A

nonpregnant female 65ml/kg

pregnant 85-90ml/kg

112
Q

CO changes from pregnancy

A

inc by 40% at terms
inc maternal HR (6 weeks)
inc SV (8-10 weeks)- due to dec SVR

skin bf inc by 3-4 x; warm skin, flusing, itching

113
Q

renin and estrogen changes with pregnanct

A

inc renin -> inc aldo -> inc na retention -> h20 reabsorb -> inc plasma volume -> inc SV/ CO

estrogens inc angiotensin -> inc aldo

114
Q

Uterine blood flow pregnant vs not

A

non preg = 50 ml/min
preg = 700 ml/min (12% of CO)

115
Q

what mediators cause a decrease in SVR

A

progesterone, prostacyclin, relaxin, estrogen -> vasodilation and VD of renal vasculature -> inc bf

20% lower than pre preg -> dec afterload …..High flow, low resistance.

116
Q

LV hypertrophy with pregnancy

A

50% inc in LV mass by term. (eccentric hypertrophy) to accommodate for inc blood volume/ preload.

position change to left/ anterior. PMI @4th ICS mid clav.

117
Q

EKG changes with preg

A

t wave inversion in lead 3
lead 1 and AVL +
Lead 2 and AVF -
shorter PR interval (inc sns @ 3rd trimester -> inc AV conduction velocity)
Inc QT interval

HR inc -> tachyarrhythmias / CT/PVCs/PACs (inc sns and usually benign)

118
Q

causes of tachyarhthmias during pregnancy

A

inc ion channel conduction
inc heart size
change in autonomic tone
hormones

119
Q

Valvular changes in pregnancy

A

tricuspid and pulmonic regurg in 90% of pts
mitral regur in 30% of pts

reversible

120
Q

S/s of aortocaval compression and when does it start and how do you treat it

A

tachycardia-> bradycardia
N/V
Pallow/ sweating
LOC
fetal distress

starts at 13-16 weeks
treat w/ LUD

121
Q

autotransfusion amount with contractions

A

Hr increases and autotransfusion of about 300-500 ml of blood from the uterus to the general circulation with each contraction

122
Q

What are the pregnancy hormones

A

Estrogen and progesterone

123
Q

Estrogen and progesterones role in pregnancy

A

estrogen inc the number and sensititivty of progesterone receptors in the respiratory centers in the brain

progesterone inc resp center sensitivity to CO2
bronchodilator
Hyperemia/edema of resp passages
activates spinal cord Kappa opioid r = anaglesia

124
Q

Relaxins role in pregnancy

A

causes ligamentous attachment to lower ribs to relax -> barrel chest -> inc subcostal angle and widened Ap and transverse diameter of chest wall -> preserves TLC

inc joint mobility; sacroiliac pain/ knee pain

overstretching of joints = possible

125
Q

lung volume changes during pregnancy

A

dec in FRC at term
dec ERV/RV -> dec reserve
when supine frc decreases even more

VT increases (due to inc Co2 production and resp drive from inc progesterone)

inspiratory capacity increases

TLC/ VC stay the same

126
Q

pleural pressure in pregnancy

A

becomes more + -> earlier closure of small airway -> closing capacity may exceed FRC -> V/Q mismatch because of closure of small airway -> dec O2 saturation

127
Q

Oxygen consumption changes with pregnancy

A

inc by 20% due to inc metabolism and inc metabolic needs of fetus/ uterus/ placenta

128
Q

Reasons for inc WOB that begins in the first trimester

A

inc resp drive
inc O2 consumption
dec PaCO2
large pulmonary blood volume
Anemia
nasal congestion

129
Q

Normal blood gas for pregnant women

A

Respiratory alkalosis

PaCo2 decreases ~ 8-10 mmhg
PaO2 increase ~ 5mmhg

130
Q

Anemia in pregnancy

A

dilutional anemia from inc plasma volume more than the increased red cell mass. also iron needed to make RBCs and is treated with oral iron formulation (iron deficiency anemia)

HBG drops ~ 2.4 g/dl at 36 weeks
Hct dec ~6.5%

abnormal < 11g/dl
hemoconcentration/ preeclampsia > 13 g/dl

131
Q

Platelet changes in pregnancy

A

normal 165-415,000mm3

< 150,000 = thrombocytopenia; may be idiopathic, htn disorder or gestational

transfuse if < 50,000

132
Q

Coag changes with pregnancy

A

hypercoagulable
inc in factors (excep 2,5,11,13)
inc fibrinogen (factor 1 ) > 400 mg/dl at term

133
Q

WBC changes with pregnacy

A

inc to 9-11,000 and inc up to 34,000 in labor

but due to polymorphonuclear leucocyte function being impaired -> inc risk and severity of infection.
and humora antibody titers decrease to certain viruses; measles, influenza A and herpes simplex

134
Q

Gi changes with pregnancy

A

LES tone decreases. lowest at term
gastric emptying is only delayed during labor

135
Q

Aspirator risk till how long after pregnancy

A

4-6 weeks postpartum. LES tone returns to normal at 4 weeks and uterus needs 6 weeks to get back to normal size

136
Q

High aspirator risk/ mendelsons syndrome

A

gastric pH < 2.5, gastric volume > 25

mendlesons; perioperative aspirator of gastric contents. inflammatory response of lung parenchyma

137
Q

Hepatic changes with pregnancy

A

inc splanchnic and portal and esophageal pressure
inc liver enzymes and cholesterol

dec total protein and dec albumin-globulin ration -> dec colloid oncotic pressure

138
Q

Pseudocholinesterase activity in pregnacy

A

dec by 25% before delivery and by 33% on the 3rd postpartum day. returns to normal in 2-6 weeks. usually not enough to cause prolonged paralysis after single dose of succ.

139
Q

cholestasis s/s

A

pruritis, high serum bilirubin, abnormal liver function tests

3rd trimeester 1/100 ppl
biliary stasis + inc bile secretions
inc risk of cholethiiasis, inc risk if subsequent pregnancy, cholecystectomy?

140
Q

renal changes in pregnancy

A

75% inc in renal blood flow.
inc GFR
inc Creat clearance -> dec serum creae
dec BUN

141
Q

Endocrine changes in pregnacy

A

thyroid enlarges (difficult airway?)
hypthyroidismm -> fetal cognitive issues, spont abortion, growth restriction and placental abruption if not treated

pancreas insulin resistance due to human placental lactogen, inc blood glucose

adrenal; inc cortisol (by 100% in 1st trimester and 200% at term)
plasma endorphins increase

pituitary ; ant pit inc prolactin secretion -> prep for breast feeding/ acne
post pit ; oxytocin section -> stimulation or uterine contractions, responsible for breast milk let down, bonding hormone.

142
Q

Musculoskeletal changes with pregnacy

A

affect of Relaxin

nerve compression (sciatic pain common, meralgia parenthetic; comp of LFCN (tingling/ numbness/ burning pain)

lumbar lordosis change of center of gravity/ pelvic tilt. narrowing of intervertebral spaces.

143
Q

CNS changes with pregnancy

A

inc cbf
inc BBB permeability
inc pain threshold
engorgement of epidrual veins
dec CSF volume -> greater spread of LA

dec total dose of LA requirement to produce same level of epidural/ spinal

NMBD; inc roc/ vec sensitivity
dec ACHe activity

144
Q

What are the sources of uterine blood flow

A

primary; uterine arteries (branch off the internal iliac (hypogastric) arteries)
secondary; ovarian arteries (branch off the aorta @L4)

145
Q

what are the characteristics that the rate / amount of transfer depends on in the intervillous space

A

concentration gradient
permeability
restriction of movement; bound to placental tissues/ proteins = minimize fetal exposure/ accumulation

146
Q

how much blood pools in the intervillous space and how does blood enter the space

A

350 mls

enters via the spiral arteries

147
Q

causes of dec uterine arterial pressure

A

aortocaval compression
hypovolemia (bleeding/ dehydration)
hypotension (neuaxia/ drug induced/ prop, mag, VA, opioids).

tx; give fluids/ vasoconstriction

148
Q

causes of inc venous pressure

A

IVC compression
contractions/ pushing effect; inc contraction -> inc venous pressure/ hyperemia
tachysystole (oxytocin/ cocaine/ methamepheamines)
sz

149
Q

causes of inc uterine vascular resistance

A

Stress response/ hypotension -> inc catecholamines
exogenous catecholamines

150
Q

effects of ephedrine on the fetus

A

x placenta; inc fetal metabolic requirements -> dec fetal pH, base excess and umbilical O2 content.

151
Q

Phenylephrine effect on fetus

A

vasopressor of choice if repeated doses are needed… results in inc uterine vascular resistance -> dec UBF

152
Q

what are the effect of inc LA concentration

A

arterial constriction
inhibition of endothelium mediated vasodilation
stimulation of myometrial contraction

153
Q

IV dexmedetomidtine/ clonidintes affects on UBF

A

IV admin = dec ubf -> inc UVR. VD at low dose. inc dose -> vasoconstrction -> uterine contractility / inc UVR/ intrauterine pressure

154
Q

magnesium effect on uterine blood flow

A

increase UBF, relax smm, vasodilation

155
Q

Volatiles effect on UBF

A

0.5-1.5 mac -> minimal efffect on ubf

inc mac -> dec CO/BP-> dec UBF

156
Q

sides of the placenta

A

yellow side = chorionic plate = fetal size
purple side = basal plate = maternal side

157
Q

what are the means of placental transfer

A

passive diffusion
facilitated diffusion
active transport
pinocytosis

158
Q

what are the characteristics for drugs to transfer to the placenta

A

passive transfer (blood flow dependent)
lipid solubility (highly lipid soluble = bilayer penetration) -> trapping
protein concentration ; higher bound = less transfer
PKA; non ionized cross placenta
molecular size < 500 daltons

159
Q

describe ion trapping

A

fetus w/ lower pH / higher H+ concentration the extra H+ will bind to the non ionized form of the drug and trap in fetal circulation

160
Q

Drugs that cross the placenta

A

atropine
scopolamine
beta antagonists
nitroprusside
volatiles
benzodiazepines
lidocaine
opioids
ephedrine
propofol
ketamine
etomidate
dexmed
acetaminophen
neostigmine *
edrophonium
warfarin

161
Q

How is drug teratogenicity graded

A

A = least dangerous
B= tylenol
C = benzos (clef palate formation)
D = most dangerous

Nitrous = not classified. harmful to dna synthesis in high doses

162
Q

P50 changes of fetal vs adult

A

fetal hbg p50; 19 mmhg = partial pressure of oxygen when 50% of HCG is saturated.

the 2 alpha and 2 gamma subunits on the fetal hbg = inc affinity for O2. = higher p50

163
Q

Maternal bohr effect

A

because the fetal blood has a higher Co2 and a lower ph -> decreased affinity of O2 for hbg -> right shift in O2 curve for the maternal.

164
Q

Double bohr effect

A

fetus shifts oxyhbg curve to the left by; Co2 diffuses to maternal blood = dec co2 in fetal blood -> alkaline environment / inc pH -> left shift in O2 cuve -> inc afinity for O2 on hbg.

165
Q

what does fetal monitoring reflect

A

nonspecific reflection of fetal acidosis

166
Q

how are contractions quantified

A

quantified over 10 min
averaged over 30 min
beginning of one contraction to beginning of next
=/< 5 contraction in 10 min is normal

167
Q

what is tachysytole

A

> 5 contractions in 10 min period

168
Q

treatment of tachysystole

A

stop pitocin
nitroglycerine
beta - 2 adrenergic receptor agonist (terbutaline)

169
Q

causes of fetal tachycardic

A

FHR > 160

chorioamniosis
sespsis
acute hypoxia
fetal heart failure
anemia
maternal hyperthyroidism
maternal fever
epi/ ephedrine
beta 2 adrenergic agonists (terbutaline/ritodrine)

170
Q

Causes of fetal bradycardia

A

initial response to hypoxemia
umbilical cord compression
fetal head compression
hypothermia
maternal hypotension
maternal hypoglycemia
congenital heart block

171
Q

accelerations

A

period of inc FHR at least 15 bpm, lasting at least 15 seconds

signs of variability

normal/ healthy

172
Q

variability

A

fluctuations in baseline FHR
irregular in amplitude and frequency
quantified as amplitude of peak to trough of bpm

most important indicator of fetal oxygen status

absent - none detected
minimal - range less than 5 bpm variation
moderate - range 6-25bpm
marked- > 25bpm

173
Q

causes of absent variability

A

fetal sleep cycles
prematurity
arrhythmias
fetal tachycardia
Pre-existing neurologic abnormality
congenital anomalies
severe hypoxemia
beta-adrenergic antagonists
antenatal corticosteroids (betamethasone)
ethanol
GA
dexamethasone
benzos
mag sulfate
systemic opioid analgesia
promethazine

174
Q

causes of increased/ marked variability

A

fetal stimulation
mild and transient hypoxemia. umbilical cord compression in 2nd stage of labor
maternal illicit drugs/ stimulants

175
Q

decelerations

A

Early; gradual. onset to nadir = > 30 sec. nadir is at peak contraction. FHR < 20bpm.

late; gradual. delayed onset. begins at peak contraction or after contraction is over. onset to nadin > 30 sec. smooth/ shallow.

variable; onset, depth, duration vary w/ contraction. irregular. abrupt dec and return. onset to nadir < 30 sec. fhr < 15 bpm dec. lasts 15 sec or longer. < 2 min duration.

176
Q

Earlies indicate

A

uterine contraction = benign
head compression -> vagal nerve stimulation

usually limited to the active stage of labor
cephalopelvic disproportion if seen in early labor

177
Q

Variable decel indications

A

transient hypoxemia
cord compression

if frequent in early labor -> cord occlusion
may also indicate oligohydraminos (low amniotic fluid)

178
Q

severe decel

A

FHR < 70 bpm
decrease in FHR > 60 bpm from baseline

contraction duration > 60 seconds
decreased umbilical blood flow
impaired fetal CO

minimal/ absent variability -> concern for hypoxia

179
Q

Late decels indication

A

can be benign as long as variability is present. dec / absent varilibty = ominous.

causes; hypoxemia, cont hypoxemia ->lactic acidosis
myocardial decompensation/ /failure
chorioamniosentsis
post term gestation
uterine hyperactivity
maternal hypotension/ htn disorder/ cardiac dz
maternal smoking
maternal anemia
placental abruption/ previa

180
Q

prolonged decel and its cause

A

dec in FHR >/= 15 bpm lasting 2 min or more but < 10 min

causes; cord compression, maternal hypotension/ hypoemia. tetanic uterine contractions
prolonged head comp in 2nd stage of labor

181
Q

Sinusoidal pattern

A

cycle frequency of 3-5 cycles/ min
amp range 5-15 bpm
persist > 20 min
required ob intervention

causes; fetal anemia, RH disease (incompatible blood), severe hypoxemia

182
Q

Category 1 FHR tracing category

A

predictive of normal fetal acid-base status​

Baseline FHR 110 - 160 bpm​
Moderate baseline variability​
No late or variable decelerations​
Early decelerations present/absent​
Accelerations present/absent

183
Q

Category 2 fhr tracing category

A

Indeterminate​

Fetal tachycardia​
Absence of induced accelerations after fetal stimulation​
Prolonged decelerations > 2 mins < 10 mins​
Recurrent late decels w/ moderate variability​
Not predictive of abnormal fetal acid-base status

184
Q

Category 3 FHR tracing

A

Abnormal fetal acid-base status​

Sinusoidal FHR pattern​
Absent FHR variability w/recurrent late decels​
Recurrent variable decels​
Sustained bradycardia

185
Q

Management of Category III Tracings

A

Maternal position change​
Discontinue labor augmentation​
Treatment of tachysystole​
Surgical delivery

186
Q

APGAR scoring

A

Five parameters assessed at 1 & 5 minutes, given a score of 0, 1 or 2:

Heart rate​; absent < 100, >100
Respiratory effort​, absent, irregular, crying
Muscle tone​; limp, some flexion, movement
Reflex irritability​; none, grimace, coughing/sneezing
Color; cyanotic, trunk pink extreme blue, pink

8-10 = normal​
4-7 = moderate impairment​
0-3 = immediate resuscitation required​

Risk for mortality
inversely proportional to 1 minute score

187
Q

second stage of labor is when its lasts greater than….

A

3-4 hrs

188
Q

pain during first stage of labor

A

mechanoreceptor stimulation; stetching of lower uterine segments and cervic

visceral pain; transmitted bia unmylinated c fibers. enter SC at T10-L1. hard to localize. lower abd/ back. difficult to treat w/ opioids.

Latent phase; T10-12
Active phase T12-L1.

amenable to blockade of peripheral afferents

189
Q

pain during the Second stage of labor

A

somatic pain; tranmitted via myelinated a delta fibers via the pudendal nerve. sharp, easy to localize. stretching and compression of pelvis and perineal structures.

T12-S4.

visceral pain is still significant as contractions continue

190
Q

Where is the kyphotic apex of the thoracic curvature

A

T8 shift to T6….increased risk of cephalad spread

191
Q

absolute and relative contraindications for neuraxial anesthesia

A

absolute;
Patient refusal
Uncooperative patient
Uncontrolled hemorrhage w/ hypovolemia
Epidural site skin/soft tissue infection
Moderate to severe bleeding issues/clotting disorder
Anticoagulation

relative;
Elevated ICP d/t mass lesion
Local anesthetic allergy
Language barrier w/o interpreter
Severe fetal depression
Severe maternal cardiac dz
Active coagulopathy
Untreated systemic infection
Pre-existing neurologic deficit
Skeletal anomalies
Hardware in spine

192
Q

placement of CSE

A

L2-3 / L3-4 / L4-5

193
Q

What should be monitored after an intervention (epidural/spinal)

A

Quality of analgesia
Progress of labor
Sensory level (Ice vs. “Pin Prick”)
Intensity of motor blockade
Maternal vital signs
FHR tracings

194
Q

Treatment of pruritus from intrathecal opioids

A

Centrally acting mu-opioid antagonist;
Naloxone 40-80 mcg IV bolus or 1-2 mcg/kg/hr
Naltrexone 6 mg po
Partial agonist-antagonist;
Nalbuphine (Nubain) 2-5 mg IV bolus
Butorphanol (Stadol) 1-2 mg IV bolus

195
Q

Types of skin incisions

A

Low transverse and low vertical/ midline

196
Q

Types of uterine incision

A

Low transverse
vertical
classical

197
Q

Describe the bezold jarish reflex

A

mechanoreceptors in the wall of the LV responding to “low stretch”

triad; vasodilation, hypotension, bradycardia

prevented with zofran

198
Q

phenylephrine gtt rate

A

0.1-0.7mcg/kg/min or 25-100 mcg/min

199
Q

Testing blockade quality

A

blunt needle; charp on your arm, can you feel it being here, can you feel me touching but you are not the sharp?

200
Q

Average depth for LOR/ to reach the ligamentum flavum

A

4-6 cm you will want to leave 4-6 cm of catheter in the patient

201
Q

Spinal needle gauges

A

24-25 gauge

202
Q

Number of vertebra vs number of nerves

A

33 total vertebra, 31 total pairs of spinal nerves

203
Q

high and low points of spinal colum

A

high = C3 and L3
low = T6 and S2

204
Q

ligaments of the spine

A

suprspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura matter
subdural space
arachnoid mater
subarachnoid space
pia matter

205
Q

Spinal cord ends at ….dural sac ends at….

A

L1 in adults
L3 in peds

dural sace ends at S2

206
Q

dura mater start and end

A

start at foramen magnum and ends at S2. fuses with the film terminal

207
Q

normal CSF volume and production rate

A

100-160 mls

produced at 20-25 ml/hr

entire volume replaced every 6 hrs

208
Q

Tuffiers line

A

intercristal line
L3-L4 space is at or above the level of the superior iliac crest

209
Q

Esters vs amides

A

different intermediate chains

same aromatic ring and tertiary amine groups

210
Q

morphine vs fent hydrophilic vs lipophilic

A

morphine; hydrophilic
fent; lipophilic

211
Q

factors that affect uptake of LA

A

factors affecting uptake of LA into neural space
concentration of LA in the CSF
surface area of the neural tissue
lipid content of the nerve
Blood flow of the nerve

212
Q

Progression of differential blockade

A

B- fibers= sympathectomy
C and A delta = loss of pain/temperature
A gamma= loss of motor tone
A beta = loss of touch/ pressure
a alpha = loss of motor function/ proprioception

213
Q

zone of differential block

A

sympathetic level is 2-6 levels higher than the sensory level
the sensory level is 2 higher than the motor level

214
Q

how are LA eliminated

A

reuptake, usually reabsoprtion (vascular)

215
Q

factors affecting intrathecal spread

A

dose, baracity, CSF volume, Advanced age/ pregnancy
patient position,
epidural injection post spinal

216
Q

CSF specific gravity

A

1.00033 (pregnanct)
1.00067 (men)

217
Q

how long are you able to determine dermatome spread with positioning

A

5 minutes

218
Q

Where does sympathetic outflow oringinates

A

T6-L2

219
Q

Names of cutting needles

A

quincke
pitkin

220
Q

Names of non cutting needles

A

sprotte
whitacre
pencan
greene
gertie marks

221
Q

Epidural needle gauge and curvature degree

A

tuohy needles is a 17 or 18 gauge
30 degree curvature

222
Q

onset of local is based on what

A

pka

223
Q

Uptake of local based on blood concetration

A

intravenous
tracheal
intercostal
caudal
paracervical
epidural
brachial
sciatic
subq

224
Q

typees of epidural needles

A

husted - 15 degree
Tuohy- 30 degrees
crawford- preferred for thoracic epidrual

225
Q

epidural catheter markins

A

two lines = 10 cm.
solid dark line = 12 cm
4 lines = 20 cm

226
Q

painless vaginal bleeding indicates….

A

placental previa

227
Q

EBL that can be tolerated w/o symptoms or changes in vital signs

A

~15%

228
Q

FFP dosage

A

FFP x 1 per 20 kg body weight as initial dose (20 ml/kg)x

229
Q

Normal and therapeutic mag levels

A

Normal = 1.7 – 2.4 mg/dL
Therapeutic range = 5-9 mg/dL

230
Q

Leading cause of death in preeclampsia

A

CVA; intracerebral/ sah ….occur postpartum

Clinical prep (21 decks)

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