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!!!!! Advanced Anesthesia I !!!!! > OB > Flashcards

OB Flashcards

1
Q

For OB patients, you want to make sure to have this type of cart

A

Difficult Airway

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2
Q

When is there the greatest cardiac demand on parturients?

A

During and right after delivery.

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3
Q

When are parturients at greatest risk for myocardial ischemia?

A

During and right after delivery, because this is the period of greatest cardiac demand

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4
Q

A parturient is considered a full stomach after ____ weeks

A

12

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5
Q

Why are pregnant women at risk for gallstones?

A

Everything in the GI tract slows down, causing stasis.

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6
Q

A fetus is considered acidotic if pH is

A

7.2

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7
Q

Fetal bradycardia is considered

A

HR < 110

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8
Q

Normal variability for a fetal HR

A

5-25 bpm

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9
Q

Normal fetal HR

A

120-160

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10
Q

What can cause fetal bradycardia? Treatment?

A

Causes

  • Maternal/fetal hypoxia
  • uterine contractions
  • vagal
  • head compression

Treat with fluids, positioning, and oxygen.

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11
Q

CO returns to normal ___ weeks post-partum

A

4 weeks

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12
Q

HR will increase by ____,

CO increases by ____,

and SV increases by _____

A

HR 23-30%

CO by 30-50%

SV by 20-50%

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13
Q

BP changes

A
  1. SVR decreases by 20%, but SBP is unchanged.
    1. This is probably due to the increase in CO and increase in blood volume.
    2. MAP however, decreases slightly.
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14
Q

What can cause hypotension in parturients?

A
  1. Supine positioning
  2. Induction agents
  3. Sympathetic blockade from regional blocks
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15
Q

Treatment of maternal hypotension

A
  • Positioning
  • fluids
  • O2
  • TED stockings
  • Ephedrine &
  • Phenylephrine
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16
Q

Compression of IVC vs. aorta

A
  • IVC compression causes a decrease in venous return, CO, and thus causes hypotension.
  • Aortic compression is usually not associated with s/s, but does decrease uteroplacental perfusion
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17
Q

Plasma volume increases by __%, but RBC volume only increases by ___

A

50%

30%

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18
Q

Coagulation in parturients

A
  1. Clotting factors increase (in preparation of delivery).
  2. Platelets remain the same or decrease slightly.
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19
Q

Plasma cholinesterases in parturients (increase/decrease)

A

Decrease.

Will/may have prolonged duration of sux!

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20
Q

EBL for vaginal delivery

A

500cc

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21
Q

EBL for c-section

A

500-700

500 with regional anesthesia

700 with general anesthesia

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22
Q

Regional anesthesia is not advised if plt counts are below

A

70,000

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23
Q

When should you suspect a PE?

A

Parturients are at risk for PE because they have increased coagulation factors; PE should be suspected if mother has:

  • SOB, chest pain, coughing up blood, arrhythmias, pain or tenderness in legs.
  • We want mothers to ambulate early and wear compression stocking!!
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24
Q

Respiratory changes in parturients

A
  1. Decrease in FRC (20%)
  2. Small airways close faster (closing capacity)
  3. Increased WOB
  4. O2 demand increases by 30%
  5. Increase in TV by 50%
  6. RR also increases
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25
Q

The dissociation curve will shift to the

A

right

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26
Q

Effects of progesterone on respirations

A
  1. Tells resp center to increase respirations
  2. Sensitizes the resp center to CO2
    • increases MV to drive maternal PaCO2 to 30-32,
    • causes a compensated respiratory alkalosis with excretion of bicarb
  3. Chest muscle relaxation, allowing the chest wall to expand more easily
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27
Q

ABG of pregnant women

A
  • Remember that they have increased sensitivity to CO2 d/t progesterone, so they have an increased MV.
  • This results in a compensated respiratory alkalosis
    • ​normal pH (compensated)
    • low pCO2 (hyperventilations)
    • low bicarb (excreated by kidneys)
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28
Q

Why is it important for parturients to have oxygen?

A
  • Increased oxygen consumption
  • decreased FRC
  • decreased CO when supine
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29
Q

Why is hypoventilation in parturients so bad?

A
  1. It decreases O2 availability to fetus
  2. Also, mothers can quickly develop acidosis
    • causing BVs to constrict and decreasing uteroplacental flow
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30
Q

Will IAs have a faster or slower effect on parturients?

A

Faster d/t increase in MV

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31
Q

Choice of ETT size in parturients

A

6.0-7.0

Generall err on the smaller side,

because they may have edematous airways

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32
Q

Clinical implication of full stomach past 12 weeks rule

A
  • Bicitra given to all laboring women
  • Reglan H2 Antagonists (Ranitidine, Famotidine)
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33
Q

GI changes in pregnancy

A
  • Increased gastric acidity
  • peristalsis is slowed,
  • decreased lower esophageal spincter tone
  • stomach displaced upward and 45 degrees to the right
  • Labor pains and opioids delay gastric emptying and promote emesis
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34
Q

CNS changes in pregnancy

A
  • Increase in endorphine
    • higher pain threshold
  • Increased sensitivity to IAs, LAs, and opioids
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35
Q

MAC requirements decrease by ___% in parturients

A

40%

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36
Q

Renal Changes in pregnancy

A
  1. Increase in RBF and GFR d/t increased CO
  2. Because of this, lower serum BUN/Cr values
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37
Q

Formula for Uterine Blood Flow

A

(Uterine arterial BP - Uterine Venous BP)

(Uterine vascular resistance)

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38
Q

Normal uterine blood flow at term

A

500-700 cc/min

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39
Q

Why is maternal hypotension such a big deal?

A
  • The uterine vascular bed lacks autoregulation!!!!
  • Maternal UBF is dependent on BP and CO
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40
Q

Factors that increase uterine vascular resistance, and thus decrease UBF

A
  1. Oxytocin
  2. contractions
  3. ketamine
  4. abruptio placentae
  5. severe HTN
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41
Q

Drug transfer across the placenta depends on

A
  1. MW
  2. Size
  3. Lipid Solubility
  4. Maternal drug concentration
  5. Maternal and fetal pH (more non-onized means more transfer)
  6. Low protein binding
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42
Q

What is the single best non-invasive indicator of fetal well-being??? ****

A

Fetal HR variability

Should be between 5-25bpm

43
Q

Causes of fetal tachycardia

A
  1. Chronic fetal distress
  2. Maternal Fever
  3. Certain medications (epi, ephedrine, atropine, etc)
44
Q

Fetal bradycardia is a FHR

A

HR < 110

45
Q

Causes of loss of variability

A
  1. CNS depression that may be due to:
    1. asphyxia, general anesthetics, neurologic abnormalities or from maternal opioids
46
Q

Early decels

A

Develop with uterine contraction.

  1. Head compression from contraction causing increased vagal tone.
  2. These decels are transient and well tolerated by the fetus.
47
Q

Late decels

A

Begin AFTER onset of uterine contraction.

  1. May be caused by CNS ischemia, myocardial ischemia or fetal hypoxia.
  2. This is an ominous sign!!
  3. Maternal hypotension must be treated.
48
Q

Variable Decels

A

Variable in shape and timing, short in duration, and occurs within 30 seconds of onset.

  1. Caused by cord compression, which activates the carotid baroreceptor reflex.
  2. If the compressions are frequent or prolonged, it could result in fetal asphyxia.
  3. Most common pattern observed in the intrapartum period.
49
Q

Intrauterine resuscitation

A
  1. Supplemental oxygen
  2. LUD or knee-to-chest positioning
  3. Rapid fluid infusion
  4. Check maternal vital signs, and treat hypotension with pressors
  5. Stop oxytocin if it was being given, and begin tocolysis with terbutaline or NTG
  6. Assess level of blockade for spinal/epidural
  7. Amnioinfusion
    • inserting fluid in the uterine cavity to decrease cord compression
  8. C-section
50
Q

Opioids in the laboring woman

A

Commonly given, although data suggests they provide limited analgesia.

  • Meperidine (Demerol) 25-50mg
    • most common
    • metabolite normeperidine can linger in the fetal circulation and cause depression and will lose variability.
  • Opioids also have unwanted side effects
    • N/V, resp depression, sedation, orthostatic hypotension, and neonatal depression.
  • PCAs of fentanyl or remifentanil may be used.
  • Agonist/antagonists (butorphenol and nalbuphine)
    • decreased N/V and “ceiling effect” of respiratory depression.
    • Nalbuphine (Nubain) has less dysphoria than butorphenol.
51
Q

Gases for laboring pain

A

Entonox - 50/50 mix of nitrous and O2

Sevoflurane

52
Q

Stages of Labor and Blocks Needed

A
  1. 1st = Beginning of painful contractions to full dilation -
    • Longest Stage
    • Mostly visceral pain
    • T10-L1 innervation
  2. 2nd = Complete dilation to delivery
    1. Most painful stage (somatic pain)
    2. L2-S4 innervation
  3. 3rd = From delivery of baby to delivery of placenta
53
Q

Midazolam in laboring women

A
  • Low doses 0.5-1mg to provide anxiolysis
  • but make sure they remember the delivery
54
Q

Epidural catheter is inserted __ - __cm into epidural space for parturients

A

4-6 cm

Normal population = 2-3cm

55
Q

LA of choice for emergency c-section

A

Chloroprocaine (d/t highly rapid onset)

56
Q

Rules for epidurals

A
  1. Parturient should be at least 4 cm dilated
  2. Test dose between contractions
  3. Fluid load with 500 cc crystalloids before induction
57
Q

CSE is great option for women, but carries increased risk of…

CSE = combined spinal and epidural

A

non-reassuring FHR patterns and fetal bradycardia

58
Q

Treatment for Post Dural Puncture Headache

A
  1. Bedrest
  2. Caffeine
  3. Hydration
  4. OTC analgesics
  5. Epidural blood patch
59
Q

Most common reasons for having a c-section

A
  1. Previous c-section
  2. Cephalopelvic Disproportion (CPD)
  3. Failure to progress
  4. Malpresentation
  5. Prematurity
  6. Non-reassuring fetal status
60
Q

This is the preferred muscle relaxant for c-section under general anesthesia

A
  1. Sux (guessing d/t short duration) and need for RSI If can’t use sux, rocuronium is a suitable alternative.
  2. Do not give defasiculating dose of roc (they have increased sensitivity
61
Q

Induction agent of choice if the mother is having a hypotensive crisis

A

Ketamine 1-1.5 mg/kg

62
Q

Time between incision of the uterus and delivery of the fetus MUST be less than ___ minutes

A

32

63
Q

Optimal dose of bupivacaine for spinals for C/S

A

12 mg Provides block for 1.5-2 hours

64
Q

Need this levels spinal block for C/S

A

T4

65
Q

How to prevent hypotension with spinal blockade

A

2L crystalloid

LUD

Pressors

66
Q

What is the first line pressor for parturients?

A

Ephedrine

67
Q

Top causes of maternal death related to anesthesia

A

1 Airway problems #2 LA toxicity

68
Q

PIH definition

A

Pregnancy Induced HTN BP > 140-90 or BP > 30 points SBP from baseline or >15 points DBP from baseline Severe HTN in 160/110

69
Q

PIH can cause

A

Cerebral hemorrhage, abruptio placentae, liver and renal failure, DIC

70
Q

Risk factors for PIH

A

Primiparity Multiple gestation Chronic HTN African Americans Chronic Renal Disease Obesity Diabetes Family history of pre-eclampsia These should all make logical sense

71
Q

What is preeclampsia?

A

A hypertensive disorder. New onset of HTN that develops after 20 weeks gestation, along with proteinuria. HTN without proteinuria is just PIH.

72
Q

Symptoms associated with preeclampsia, and other disorders it can lead to

A
  1. Associated with vasoconstriction (causes HTN)
  2. edema (proteinuria)
  3. hypovolemia,
  4. coagulation abnormalities and poor organ perfusion
  5. Can lead to cerebral bleeds
  6. pulmonary edema
    • (dilutional hypovolemia decreases oncotic pressure and also increased pulmonary cappilary perneability)
  7. hepatic rupture
  8. and HELLP syndrome.
  9. May experience epigastric pain if there is liver involvement.
73
Q

Mild vs. severe preeclampsia

A

Mild = BP > 140-90 or BP > 30 points SBP from baseline or >15 points DBP from baseline

  • Proteinuria > 500mg/day

SEVERE = BP > 160/110

  • Proteinuria > 5g/day
  • CNS changes, blurred vision
  • Hepatic involvement/epigastric pain
  • Pulmonary edema
74
Q

What is eclampsia?

A

Defined as preeclampsia with seizures. This is a life threatening emergency

75
Q

Treatment of pre-ecclampsia and ecclampsia

A

Pre-ecclampsia

  • Goal = DBP < 110
  • Labetolol, hydralazine (may also use NTG or nefedipine)

Ecclampsia

  • magnesium sulfate (bolus 4g over 10 minutes then 1g/hour)
  • LUD, fluids, oxygen antihypertensives, coag studies May need immediate fetal delivery
76
Q

Goal of treatment of preeclampsia

A
  • Control HTN
  • prevent seizures
  • Correct coagulation issues
  • delivery of the fetus (the only definitive treatment)

(want to gradually decrease the HTN to avoid fetal distress could

77
Q

Why is Magnesium Sulfate used?

What are its effects?

A
  • Drug of choice for hyperreflexia, and prevention/control of seizures related to preeclampsia and eclampsia
  • Effects:
    • Relaxation of vascular, bronchial, and uterine smooth muscle** (HYPOTENSION)
    • Mild sedative
    • Potentiates NDMRs
    • Crosses the placenta (causes neonatal hypotonia and resp depression)
78
Q

Dose of Mag Sulfate therapy

A

Bolus 4g over 10 min

Then maintenance of 1 g/hr

79
Q

Mag Sulfate effects can be reversed with

A

Calcium Calcium Gluconate 1g

Calcium Chloride 300mg

80
Q

Paralytic of choice for those on Mag Sulfate therapy

A
  • Sux 1mg/kg
    • NEVER give defasciculating dose prior
    • MGSO4 will POTENTIATE all NMBs, and
      • give 1/3 to 1/2 of the normal maintenance dose
81
Q

Effect of Pressors for those on mag therapy

A
  • Decreases the response of alpha agonists
    • neo and ephedrine won’t work as well
    • But ephedrine is preferred to neo
82
Q

What is HELLP syndrome?

A

Severe form of preeclampsia characterized by:

  • Hemolytic anemia
  • Elevated Liver enzymes
  • Low Platelet counts

(Can be mild or be so severe that it causes multiorgan failure)

83
Q

S/S of HELLP syndrome

A

Hallmark sign is hemolytic anemia!!

  • Epigastric pain = most common initial symptom (90%)
  • Malaise (90%)
  • N/V (50%)
84
Q

Risks of vaginal birth after cesarean

A
  1. 1% chance uterine rupture–> emergency for both mother and fetus
  2. Uterine infections
  3. May need blood transfusion
  4. Risk of an emergency c-section
85
Q

How to relax the uterus

A

Sevoflurane

Nitroglycerin 50-100mcg

86
Q

Multiple gestations is associated with

A
  1. Abnormal fetal positions
  2. PIH
  3. Premature labor
  4. Increased risk of potpartum hemorrhage d/t uterine atony
  5. Higher anesthesia morbidity (more aortocaval compression, even lower FRC, high risk for spinals and epidurals)
87
Q

Definition of preterm labor

A
  1. Regular uterine contractions that occur between 20-37 weeks of age.
  2. This is the leading cause of perinatal morbidity and mortality***
  3. Fetus at high risk for resp issues and intracraniall hemorrhage (d/t soft intracranial vault)
88
Q

Treatment for premature labor

A
  1. Bedrest FHR monitoring
  2. Check for Premature Rupture of memebranes
  • Tocolytic agents
  • CCBs (nifedipine)
  • NSAIDs (indomethacin and ketorolac)
  • B2 agonists (Terbutaline)
  • Mag sulfate
  • Steroids for surfactant production
89
Q

Affects of NSAIDs on the fetus

A
  • Constriction of ductus arteriosus
  • pulmonary HTN
  • renal dysfunction
  • intraventricular hemorrhage
90
Q

EBL for C/S with hysterectomy

A

1500cc

91
Q

Treatment of postpartum hemorrhage

A
  1. Volume replacement
    • more concerned with fluid than necessarily giving blood
  2. Blood
    • give type-specific but uncrossmatched if an emergency
  3. Drugs
    1. Oxytocin
    2. Ergot alkaloids (methergin & ergocitrate)
    3. Prostaglandins
  4. Embolization of uterine/ovarian arteries
  5. Hysterectomy
92
Q

Placenta previa is characterized by

A

Painless, bright red, vaginal bleeding

93
Q

Anesthesia management for placenta previa

A
  • Prepare for high blood loss
  • Aggressive fluids (may need central line)
  • Foley
  • May need a-line
  • Large bore IVs
  • Be ready in the OR for either regional or GA.
    • Have both set up and ready to go!
    • Do regional if stable
    • If unstable, do GETA with RSI using ketamine or etomidate
94
Q

Characteristics of abruptio placentae

A
  • Painful, dark, clotted, vaginal bleeding
  • Bleeding may be underestimated because blood may be concealed behind the placenta
  • Maternal mortality high (2-11%), and fetal mortality is even higher (50%).
95
Q

What is placenta accreta?

A

Abnormally adherent placenta to the uterus

  • Placenta vera- adhered to the myometrium with invasion of the uterine muscle
  • Placenta increta- invasion into the myometrium
  • Placenta percreta- invasion through the myometrium, and into the surrounding structures of the uterine serosa and pelvis
96
Q

First sign of uterine inversion

A
  • Hypotension!
    • There is blood loss, but the fundus of the uterus is blocking it’s exit through the vajay.
    • Therefore, the first thing you will see is hypotension.
97
Q

Dose of NTG for uterine relaxation

A

1 mcg/kg

Usually 50-200 mcg

98
Q

Amniotic Fluid Embolism

A
  1. Acts as an embolus and get can lodged in places
  2. Body recognizes it as foreign, resulting in an anaphylactic/anaphylactoid reaction
    • Clinically looks like PE + anaphylaxis
    • 60-80% mortality rate!
99
Q

In morbidly obese patients, LA volume should be (increased/decreased)

A

Decreased

(less space in the epidural space)

100
Q

If a parturient requires non-OB surgery, this is the most vulnerable time for them to have it

A
  • 3-8 weeks gestation, because there is lots of growth and development occurring.
  • Regional is always best option!
  • Minimizes exposure to systemic anesthetic medications
101
Q

Parturients often present for these non-OB surgeries

A

Cholecystectomies and appendectomies

102
Q

Avoid these known teratogens especially in the first semester

A

N2O and benzos

benzos linked to cleft lip/palate

103
Q

FHR monitoring isn’t needed if fetus is less than ___ weeks

A

20

(no chance of viability even if emergency occurs)

!!!!! Advanced Anesthesia I !!!!! (9 decks)

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