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NUNA 693 Obs/Regional > OB: C-Section: Regional vs. General Anesthesia > Flashcards

OB: C-Section: Regional vs. General Anesthesia Flashcards

1
Q

most common indications for C-section

A

Dystocia
Malpresentation
Non-reassuring fetal status
Previous cesarean delivery

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2
Q

Can be performed for obstetric or medical indications or at the request of the parturient. Typically planned and performed prior to the onset of labor.

A

Elective C-Section

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3
Q

Typically occur after the onset of labor (exception: i.e. Non-reassuring fetal nonstress test [NST]). Can be due to a variety of maternal and fetal indications

A

Urgent/Emergent C-section

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4
Q

TOLAC

A

trial of labor after cesarean

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5
Q

VBAC

A

vaginal birth after cesarean

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6
Q

_____ _____ ______ _____ (super STAT emergencies)
Better surgical exposure and visualization
Faster exposure

A

Midline vertical (skin) incision

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7
Q

_____ _____ _____ ______
Better cosmesis
Better wound strength

A

Horizontal suprapubic (skin) incision

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8
Q

Horizontal uterine incision

_______ incidence of uterine dehiscence or rupture in subsequent pregnancies

A

lower

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9
Q

Horizontal uterine incision

______ risk of infection

A

reduced

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10
Q

Horizontal uterine incision

______ blood loss

A

decreased

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11
Q

Horizontal uterine incision

______ risk of adhesions to bowel and omentum

A

decreased

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12
Q

Vertical uterine incision usually only seen if:

Lower uterine segment is underdeveloped (prior to ___ weeks)

A

34

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13
Q

Vertical uterine incision usually only seen if:

Delivery of a preterm infant in a parturient who ___ ____ _____

A

has not labored

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14
Q

Vertical uterine incision usually only seen if:

Some ____ _____ and/or malpresentation

A

multiple gestation

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15
Q

Vertical uterine incision usually only seen if:

Low lying anterior ____ _____

A

placenta previa

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16
Q

Operative Technique - Uterine exteriorization (after delivery)

Good, facilitates ________ and facilitates repair of uterine incision

A

visualization

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17
Q

Operative Technique - Uterine exteriorization (after delivery)

controversial effects on blood loss and infection, higher rate of ______, increased risk of ______ ______, and increased post operative ______

A

N/V
air embolus
pain

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18
Q

Complications of C-Section

A

Hemorrhage (MAIN SX COMPLICATION - TEST)
Infection
Thromboembolism
Ureteral and bladder injury
Abdominal pain
Uterine rupture in subsequent pregnancies
Death

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19
Q

Non-elective cases associated with _____ _____ than elective

A

greater risk

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20
Q

Historically, it was thought that neuraxial analgesia ___________ rate of cesarean delivery compared to other techniques. However this has been found to be unfounded in RCTs and sentinel event studies.

A

increased

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21
Q

some cesarean deliveries may be avoided with _____ ____ _____, including:

A

adequate labor analgesia

TOLAC, instrumented vaginal delivery, cephalic version, intrauterine resuscitation (pharmacologic uterine relaxation of uterine tachysystole)

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22
Q

External Cephalic Version

Breech position occurs in ____% of term singleton pregnancies

A

3-4%

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23
Q

External Cephalic Version

Vaginal breech delivery should be done with caution due to increased risk of _______ __________ ________ and risk of ________ _________

A

emergency c-section delivery
neonatal injury

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24
Q

External Cephalic Version

Neuraxial analgesia improves success of ECV by up to ____% without increased risk of fetal bradycardia, placental abruption, or fetal death.

A

50%

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25
Q

External Cephalic Version

Usually done at ___-___ weeks

A

36-37

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26
Q

External Cephalic Version

Average success rate is ___% (with a wide range)

A

58%

wide range associated with providers competency

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27
Q

External Cephalic Version

Most likely to be successful - If the presenting part has not entered the _____, Amniotic fluid volume is normal, The fetal back is not positioned ______, Patient is not obese, Position is either ____ ____ or _____

A

pelvis
posteriorly
frank breech or transverse

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28
Q

External Cephalic Version

Successful version reduces the risk of perinatal _____ & _____ of the breech position

A

morbidity and mortality

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29
Q

External Cephalic Version

Most likely complications of the ECV are:
______ FHR abnormalities
______ FHR abnormalities
Vaginal bleeding
Placental ______
Emergency cesarean delivery
Still birth

A

Transient
Persistent
abruption

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30
Q

External Cephalic Version

A high ______ dense (anesthetic>analgesic) neuraxial block will improve the success of the ECV

A

T4-T6

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31
Q

External Cephalic Version

____ if plan to discharge

A

SAB

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32
Q

External Cephalic Version

Epidural if planning to _____

A

labor

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33
Q

External Cephalic Version

Either way, have backup plan(s) to convert to ____ _____ delivery

A

emergency cesarean

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34
Q

Intrauterine Resuscitation

Intrapartum fetal compromise (nonreassuring fetal status) should prompt _____ _____ _____

A

intrauterine fetal resuscitation

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35
Q

Intrauterine Resuscitation

Optimize maternal position -
To relieve ______ compression
To relieve _____ _____ compression

A

aortocaval
umbilical cord

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36
Q

Intrauterine Resuscitation

administer supplemental _____

A

O2

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37
Q

Intrauterine Resuscitation

Maintain maternal circulation
Perform rapid IV infusion of a ___-____ ____ ____ solution

A

non-dextrose balanced salt

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38
Q

Intrauterine Resuscitation

Treat hypotension with _____ or _____

A

ephedrine or phenylephrine

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39
Q

Intrauterine Resuscitation

discontinue _______

A

pitocin (bc it increases contractions)

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40
Q

Intrauterine Resuscitation

Consider administration of a tocolytic agent for treatment of _____ _____

A

uterine tachysystole

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41
Q

Preanesthetic Evaluation

Ideally anesthesia evaluation should occur in the ____ ____ or ____ ____ trimester for high-risk patients

A

late 2nd or early 3rd

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42
Q

Preanesthetic Evaluation should include:

A

Review of maternal health
Anesthetic history
Relevant obstetric history
Allergies
Baseline BP/HR
Airway exam
Heart exam
Lung exam
Informed Consent

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43
Q

Informed Consent

Only 12% of English-speaking adults in the US are “proficient” in their health literacy skills
Health literacy is the precursor to patient ______ and to patient ____ _____

A

engagement
decision making

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44
Q

Informed Consent

70% of first time mothers are influenced by ________ and ___________ regarding labor analgesia

A

friends and family

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45
Q

Informed Consent

The most frequently utilized resource is the _______________

A

internet

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46
Q

_______ elements include the ability of the patient to meet the basic definition ofcompetence, which refers to the patient’s legal authority to make a decision about her health care. Although some cognitive functions may be compromised by the effects of pain, exhaustion, and analgesic drugs,evidence suggests that most laboring women retain thecapacityto hear and comprehend information during the consent process.

A

Threshold

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47
Q

Information elements -
provider discloses information about ______ risks
patient understands ______

A

material
information

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48
Q

_______ elements -
provider offers info in a non-coercive manner
patient gives authorization voluntarily

A

consent

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49
Q

Timeline of C-section

A
  • monitors, IV, O2
  • T4-T6 level of anesthesia established
  • left uterine displacement
  • incision and delivery
  • delivery of placenta - pitocin 30 unit IV gtt, may need more, may push smaller doses
  • closure
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50
Q

Pitocin - synthetic hormone ______

A

oxytocin

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51
Q

Pitocin - given to _____ or _____ uterine contractions or to contract uterus after delivery to prevent _____

A

initiate or augment
hemorrhage

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52
Q

Pitocin - if patient has been induced/augmented with pitocin, it may take _____ dosages to achieve adequate contraction post partum

A

higher

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53
Q

Pitocin - other uterotonic agents ______

A

unaffected

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54
Q

monitors

A

EKG
Pulse ox
capnography
oxygen and volatile agent analyzers
ventilator
peripheral nerve stimulator

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55
Q

Consent for Blood Products

Blood administration should be included in _____ _____/_____

A

informed consent/discussion.

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56
Q

Consent for Blood Products

____-_____ ______ is the leading cause of maternal mortality worldwide

A

peri-partum hemorrhage

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57
Q

Consent for Blood Products

______ ______ delivery ≤ uncomplicated elective c-section «< c-section during labor

A

Uncomplicated vaginal

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58
Q

Consent for Blood Products

preparation for hemorrhage:

A

Patient history
Consult with OB team
Ultrasound/MRI of placentation
Type and screen/cross
Contact blood bank to verify availability
Equipment (pumps/filters/pressure bags)

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59
Q

Prepping for hemorrhage

A

Large-bore IV catheters
Fluid warmer
Forced air body warmer
Availability of blood bank resources
Equipment for infusing fluids/blood products rapidly

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60
Q

There is a _____ of ______ as to which patients require a type and screen versus crossmatch. Maternal history (previous transfusion, existence of RBC antibodies), anticipated hemorrhage (placenta accreta), local institutional policies should guide decisionmaking.

A

lack of consensus

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61
Q

prepping for difficult airway

A

laryngoscope blades
LMAs
semirigid stylets
retrograde intubation equipment
at least one device suitable for emergency non-surgical airway ventilation (jet ventilation, combitube, intubating LMA)
fiberoptic intubation equipment
equipment for emergency surgical access
topical anesthetics and vasoconstrictors

(airway will worsen throughout labor)

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62
Q

Drugs for general and neuraxial anesthesia should be readily available
Including _____ & _____ medications

A

vasopressors and emergency

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63
Q

Only _____ ____ controlled substances need to be in a “substantially constructed locked cabinet”
Other drugs, including _____ ____ should be “reasonably secure”

A

Schedule II
Schedule III

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64
Q

All obstetric patients are considered a _____ stomach.

A

full

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65
Q

Patient should be asked about oral intake
_______ evidence exists regarding the relationship between recent ingestion and subsequent aspiration

A

Insufficient

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66
Q

Gastric emptying of clear liquids during pregnancy occurs _____ _____ (Remember Wong et al.,2002)

A

relatively quickly

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67
Q

Healthy patient for elective cesarean may drink modest amounts of clear liquids up to 2 hours prior to induction
_______ of _____________ is more important than volume

A

absence of particulates

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68
Q

Patients with additional risk factors for aspiration (obesity, diabetes, difficult airway, laboring) should have further __________ on a case-by-case basis or as determined by facility policy

A

restrictions

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69
Q

Ingestion of ____ ____ should be avoided in laboring patients, ___-___ hours

A

solid foods
6-8

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70
Q

Reduction in acidity and volume is thought to decrease the damage to the _____ if there is ______.

A

lungs
aspiration

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71
Q

Sodium citrate (___________ gastric pH)

A

increases

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72
Q

treat with H2 receptor antagonists, PPIs, and metoclopramide reduce gastric ________________ and ___________. (In 30-40 minutes)

A

secretion and volume

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73
Q

The combined use of antacid and H2 antagonist is ____ _____ in reducing acidity than antiacid or placebo.

A

more effective

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74
Q

ACOG recommends prophylactic administration of a narrow-spectrum antibiotic (_____ generation _______) within one hour of the start of a cesarean delivery.

A

first
cephalosporin

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75
Q

In parturients with significant beta-lactam allergy ______ & ______ are a reasonable alternative.

A

clindamycin and gentamycin

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76
Q

Higher doses should be considered with BMI greater than 30 kg/m^2 or absolute weight greater than 100 kg due to _____ _____ of ________.

A

greater volume of distribution

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77
Q

Optimal timing and value of broad-spectrum antibiotics remain ________.

A

controversial

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78
Q

Even low dose benzodiazepines may result in ______(midazolam 0.02 mg/kg)?

A

amnesia

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79
Q

For women with severe anxiety, low dose ______ or an ______ may facilitate neuraxial technique or induction

A

midazolam or an opioid

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80
Q

anxiety proph - May also mitigate feelings of distress and lessen the risk of developing _____

A

PTSD

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81
Q

Low doses of sedative or anxiolytic agents have minimal to no _____ ______.

A

neonatal effects

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82
Q

Left Uterine Displacement for all parturients after ____ ____ gestation

A

20 weeks

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83
Q

A slight (10 degree) head-up position may help reduce the incidence of ____________ after initiation of ____________ spinal anesthesia.

A

hypotension
hyperbaric

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84
Q

A more significant head-up position (30 degrees) significantly improves the _____

A

FRC

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85
Q

A 30 degree head up position may also be helpful to improve ________, ________, and view of the glottis during direct laryngoscopy

A

preoxygenation, denitrogenation

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86
Q

Trendelenburg (head down) may augment venous return and cardiac output but…. Has been reported to result in a more _____ _______ of anesthesia.

A

cephalad spread

87
Q

Lateral position

Reduction of _____ reflexes (dizziness, diaphoresis, pallor, bradycardia, hypotension)
Improved uteroplacental blood flow???
More comfortable
Limit side-to-side and front-to-back patient motion
Minimizes prominence of ____ ____
Decreased severity and duration of ______

A

vagal
dural sac
hypotension

88
Q

Sitting position

Landmark recognition (especially in obese)
Provider preference
Should _____ be utilized in fetal head entrapment, umbilical cord prolapse, footling breech presentation.

A

NOT

89
Q

Routine supplemental oxygen administration is common practice since the 70’s when Fox et al. (1971) demonstrated:

A

Improved oxygenation
Better umbilical cord acid-base measurements
Less time to sustained respiration of the neonate

(when mothers breathed 100% O2 for at least 30 minutes)

90
Q

More recent evidence has shown that routine oxygen administration may be _______ and _______ or perhaps even ________

A

unnecessary
ineffective
detrimental

91
Q

The most appropriate anesthetic technique depends on many factors:

A

Maternal
Fetal
Obstetric

(urgency and anticipated duration are important)

92
Q

Indications for Neuraxial Anesthesia

Maternal desire to witness birth and/or avoid _____ _____

A

general anesthesia

93
Q

Indications for Neuraxial Anesthesia

Risk factors for ____ ____ or aspiration

A

difficult airway

94
Q

Indications for Neuraxial Anesthesia

Presence of _____ conditions

A

comorbid

95
Q

Indications for Neuraxial Anesthesia

General anesthesia _____/_____

A

intolerance/failure

96
Q

Indications for Neuraxial Anesthesia

other benefits:

A

Plan for neuraxial analgesia after surgery
Less fetal drug exposure
Less blood loss
Allows presence of support person

97
Q

Indications for General Anesthesia

Maternal refusal or failure to cooperate with ______ technique

A

neuraxial

98
Q

Indications for General Anesthesia

Presence of comorbid conditions that contraindicate neuraxial:

A

Coagulopathy
Infection at insertion site
Sepsis
Severe uncorrected hypovolemia
Intracranial mass with increased ICP
Known allergy to local anesthetic

99
Q

Indications for General Anesthesia

Insufficient time to induce neuraxial anesthesia for ____ ____

A

urgent delivery

100
Q

Indications for General Anesthesia

failure of _____ technique

A

neuraxial

101
Q

Indications for General Anesthesia

_____ issues

A

fetal

102
Q

Neuraxial versus General

Neuraxial anesthesia has been used in more than ____% of c-sections since 1992

A

80

103
Q

Neuraxial versus General

increased use due to: (6)

A
  • Increased use of LEA
  • Increased awareness of in situ epidural catheter, even if not used in labor, may decrease necessity of general anesthesia in an urgent situation
  • Improvement of neuraxial anesthesia quality
  • Appreciation of the airway risks with general
  • Desire for limited neonatal drug transfer
  • Ability of mother to remain awake and have support person present for birth
104
Q

Neuraxial versus General

Spinal anesthesia is considered appropriate even in the most ____ _____

A

urgent settings

105
Q

Neuraxial versus General

“____ _____ Spinal”
SAB 8.1 +/- 3.8 minutes
General induction 4.5 +/-1.4 minutes

A

Rapid Sequence

106
Q

Neuraxial versus General

Maternal _____ after general anesthesia is a huge motivator for the shift

A

mortality

107
Q

Neuraxial versus General

Maternal _____ is also lower with neuraxial

A

morbidity

108
Q

Neuraxial versus General

_____ blood loss

A

decreased

109
Q

Neuraxial versus General

_____ shivering

A

decreased

110
Q

Neuraxial versus General

_____ nausea

A

more

111
Q

Neuraxial versus General

_____ intraoperative perception of pain

A

more

112
Q

Neuraxial versus General

_____ time elapsed before first request for pain meds

A

longer

113
Q

Neuraxial versus General

neonatal outcomes??

A

not a huge factor

114
Q

epidural advantages

A

No dural puncture required
Can use in situ placed earlier
Ability to titrate sensory blockade
Continuous postoperative analgesia

115
Q

epidural disadvantages

A

Slow onset of anesthesia
Larger dose required > greater risk of maternal systemic toxicity > greater fetal drug exposure

116
Q

CSE advantages

A

May be technically easier than spinal in obese
Low doses of local anesthetic and opioid
Rapid onset of dense block
Ability to titrate sensory blockade
Continuous intraoperative anesthesia
Continuous postoperative analgesia

117
Q

CSE disadvantages

A

Delayed verification of functioning epidural catheter

118
Q

one shot spinal advantages

A

Technically simple
Low doses of local anesthetic and opioids
Rapid onset of dense lumbosacral and thoracic anesthesia

119
Q

one shot spinal disadvantages

A

Limited duration of anesthesia
Limited ability to titrate extent of sensory blockade

120
Q

continuous spinal advantages

A

Low doses of local anesthetic and opioid
Rapid onset of dense anesthesia
Ability to titrate sensory blockade
Continuous intraoperative anesthesia

121
Q

continuous spinal disadvantages

A

Large dural puncture > increased risk of PDPH
Possibility of overdose and total spinal

122
Q

SAB

simple, reliable, _____ onset, _____ block (more profound than epidural), _____ amount of LA needed

A

rapid
dense
small

123
Q

SAB

decreased risk of _____ ______, minimal drug transfer to fetus, _____ and prompt recovery, most common anesthesia technique for cesarean delivery in the developed world

A

LA toxicity
predictable

124
Q

SAB

______ bevel rarely used in OB, increased incidence in PDPH

A

cutting

125
Q

SAB

___-____ needles used almost exclusively

A

non-cutting (aka pencil point needles)

126
Q

believed to cause _____ trauma to the dura (pencil point)

A

more

but the subsequent inflammation seals the hole and prevents a leak

127
Q

SAB: Needle Size

Larger needles

A

Greater tactile fidelity
More likely to withstand high resistance (bone) without damage

128
Q

SAB: Needle Size

Smaller needles

A

Lower incidence of PDPH
Use introducer needle

129
Q

SAB: Approach

Midline -
Need more patient ______ cooperation
Faster for most patients
____ painful for most patients
Easier to teach

A

positioning
Less

130
Q

SAB: Approach

Paramedian -
_____ target
Must think of the anatomy in ___ planes instead of 2
Still trying to puncture the dura in the midline
May need a ____ ____

A

Larger
3
longer needle

131
Q

SAB: Local Anesthetics

Typically use ______ doses in pregnancy than non-pregnant
Smaller CSF volume
______ movement of hyperbaric LA
Greater sensitivity

A

lower
Cephalad

132
Q

SAB: Local Anesthetics

_______ is predominant agent for SAB for Cesarean delivery in the USA

A

Bupivacaine

133
Q
A
134
Q

SAB: Adjuvant Agents - opioids

Improve comfort intra and postoperative _____
Decreased need for ______ opioids

A

comfort
intraoperative

135
Q

SAB: Adjuvant Agents

Fentanyl
- Increased postoperative opioids (after 6 hours)
- Decreased intraoperative ____ & _____
(20 mcg fentanyl is superior to ___ mg of _____)
- Large (40-65 mcg) vs. small (15-35 mcg)
(Decreased pruritus, nausea, and vomiting in small dose
No difference in supplemental analgesia need)

A

nausea and vomiting
4
ondansetron

136
Q

SAB: Adjuvant Agents

Preservative free _____
More effective for prolonged (12-24 hr) postoperative analgesia
Intrathecal morphine analgesia similar analgesia from 0.1 mg and 0.5 mg.
Occurrence of pruritus appeared to be ____ _____
Occurrence of nausea and vomiting were ___ ____dependent

A

morphine
dose dependent
not dose

137
Q

SAB: Adjuvant Agents

_____- hyperbaric

A

Dextrose

138
Q

SAB: Adjuvant Agents

Epinephrine -
increase density of _____ and _____ block, may prolong ______

A

sensory and motor
duration

139
Q

SAB: Adjuvant Agents

Clonidine - improve _____, decreases ______, reduces peri-incisional hyperanalgesia, BLACK BOX warning in OB pts because of concerns with _______ instability

A

analgesia
shivering
hemodynamic

140
Q

SAB: Adjuvant Agents

Neostigmine - reduction in postoperative _____, no effect of FHT or _____ scores, 100% of patients in the study complained of ______

A

pain
Apgar
nausea

141
Q

Use of epidural anesthesia for cesarean delivery has ______

A

increased

142
Q

Use of epidural anesthesia for elective cesarean delivery is becoming less common:

Block is ____ reliable
Higher doses (5-10 times)
_____ systemic absorption
Risk of local anesthetic toxicity
Slower onset of _____ _____
Ability to titrate level, density, and duration

A

less
Greater
sympathetic blockade

143
Q

Combined spinal epidural (CSE) anesthesia

_____ onset
Reliable anesthesia block
Ability to _____/______ blockade
Dural puncture may enhance movement of drugs into ___________ space

A

Rapid
augment/prolong
subarachnoid

144
Q

Most common local anesthetic for initiation and maintenance of epidural for cesarean delivery is ___ ______ with ______

A

2% Lidocaine with epinephrine (less than 2% may result in inadequate anesthesia)

145
Q

3% 2-chloroprocaine has most _____ onset and ______ duration
Rapid onset of hypotension
Reduced clinical efficacy if administered with _____

A

rapid
shortest
opioids

146
Q

0.5% Bupivacaine can result in surgical anesthesia
- ______ onset
- risk of LA toxicity from _______ _______

A

slower
intravascular injection

147
Q

______
50-100 mcg results in spinal and supraspinal sites of action
Improves quality of anesthesia
Does not adversely affect the neonate

A

Fentanyl

148
Q

________
10-20 mcg improves intraoperative anesthesia
Prolongs postoperative analgesia
Minimal maternal side effects, no neonatal adverse effects

A

Sufentanyl

149
Q

Clonidine
Reduced requirement for postop ______
_____tension
_____ _____ Warning

A

morphine
Hypo
Black Box

150
Q

Neostigmine
Modest postop analgesia, given after ____ _____

A

cord clamped

151
Q

Epinephrine -
Minimize systemic absorption
Increase _____ & _____ blockade density
Prolong duration
Controversial in ______ women

A

sensory and motor
preeclamptic

152
Q

Sodium Bicarbonate -
More ___-____ molecules
Speeds onset
Improves _____

A

non-ionized
quality

153
Q

Combined Spinal-Epidural Anesthesia: CSE

Combines the rapid and predictable onset of a spinal with the ability to _____ with the epidural catheter

A

titrate

154
Q

Combined Spinal-Epidural Anesthesia: CSE

Epidural needle functions as a longer _____

A

introducer

155
Q

Combined Spinal-Epidural Anesthesia: CSE

Use of ____ ____ to confirm correct positioning

A

spinal needle

156
Q

Combined Spinal-Epidural Anesthesia: CSE

May be able to use _____ spinal doses

A

lower

157
Q

Laboring patient > turns to unscheduled c-section
Assess how/is the epidural ______

A

functioning

158
Q

Local anesthesia choices

A

0.5% Bupivacaine
2% Lidocaine
3% 2-Chloroprocaine
More non-ionized molecules speeds onset, improves density

159
Q

Extension of a T10 level of analgesia to a T4 level of anesthesia typically requires ___-___ mL of local with one or more adjuvants

A

15-20 mL

160
Q

Cesarean Section General Anesthesia: Induction

Neuraxial technique is ______, but there are some cases where general is indicated

A

preferred

161
Q

Cesarean Section General Anesthesia: Induction

All parturients are considered __________________

A

full stomachs

162
Q

Cesarean Section General Anesthesia: Induction

In contrast to general surgical procedures, the abdomen is prepped and draped _____ induction of general anesthesia.

A

BEFORE

163
Q

Cesarean Section General Anesthesia: Induction

Rapid-sequence induction following ______

A

preoxygenation

164
Q

Cesarean Section General Anesthesia: Induction

Propofol 2-2.8 mg/kg is typically used to induce
______ (1-1.5 mg/kg) or ______ (0.3 mg/kg) may be used in the case of hemodynamic instability

A

Ketamine
etomidate

165
Q

Cesarean Section General Anesthesia: Induction

Succinylcholine (__-___ mg/kg) or Rocuronium (__mg/kg)

A

1-1.5
1

166
Q

Cesarean Section General Anesthesia: Induction

Smaller diameter endotracheal tube (___-___) with a semirigid stylet

A

6.0-6.5

167
Q

Cesarean Section General Anesthesia: Induction

Anticipation of a difficult airway or failed intubation attempt should invoke the ____ ____ ____

A

difficult airway algorithm.

168
Q

Indications for General Anesthesia

Maternal _____ or failure to cooperate with neuraxial technique

A

refusal

169
Q

Indications for General Anesthesia

Presence of comorbid conditions that contraindicate neuraxial:

A

Coagulopathy
Infection at insertion site
Sepsis
Severe uncorrected hypovolemia
Intracranial mass with increased ICP
Known allergy to local anesthetic

170
Q

Indications for General Anesthesia

Insufficient time to induce neuraxial anesthesia for ____ ____

A

urgent delivery

171
Q

Indications for General Anesthesia

Failure of neuraxial technique
_____ issues

A

Fetal

172
Q

General Anesthesia: Maintenance - GOALS

A

Adequate maternal and fetal oxygenation with maintenance of normocapnia (30-32 mmHg)
Appropriate depth of anesthesia to promote maternal comfort and optimize surgical conditions
Minimal effects on uterine tone
Minimal adverse effects on the neonate

173
Q

Fetal oxygenation is maximal when maternal FiO2 _____ is used, but it does not seem to alter Apgar scores.

A

1.o

174
Q

Excessive ventilation can cause uteroplacental vasoconstriction and shift the oxyhemoglobin dissociation curve to the ______.

A

left

175
Q

___ inhalational agent has been shown to be superior to others.

A

No

176
Q

ET levels of inhalational agent of _______ MAC may reduce the effect of oxytocin on uterine tone > increased blood loss.

A

1-1.5

TEST QUESTION

177
Q

IV _____ are usually withheld until after the clamping of the umbilical cord.

A

opioids

178
Q

Additional _____ _____ is rarely needed

A

neuromuscular blockade

179
Q

U-D interval longer than ____________ = lower Apgar scores and fetal pH

A

180 seconds

180
Q

Post partum women are considered full stomachs for at least ___ weeks.

A

6

181
Q

emergence and extubation

________ position
Purposeful response to verbal commands
Return of _____ _____ reflexes

A

Semirecumbent
airway protective

182
Q

Majority of deaths associated with hypoventilation or airway obstruction occurs during ______, _______, or _______!

A

emergence, extubation, or recovery

183
Q

Propofol
Rapid onset, rapid recovery, favorable side effect profile
More ____ ______ in pregnancy
Readily crosses the placenta
_____ Apgar and neurobehavioral scores for neonates than thiopental
Greater incidence of maternal hypotension
______ depth of anesthesia

A

rapid clearance
Lower
Lighter

184
Q

Ketamine
________ properties make it an ideal induction agent for urgent delivery in patient with hypotension or acute asthma exacerbation
____ _____ in preeclampsia
Hallucinations/delirium
Ketamine for induction -> decreased _____ _____ _____ than thiopental induction

A

Sympathomimetic
Not desirable
postop morphine consumption

185
Q

Etomidate
Rapid onset – minimal _______ effects
Ideal for hemodynamic instability or severe cardiac disease
Rapid ______/rapid ______
Nausea and vomiting
Transient reduction in neonatal _____ _____

A

cardiorespiratory
hydrolysis
recovery
cortisol production

186
Q

Midazolam
____ acting, ______ soluble
Typically avoided due to amnestic properties
Used with _____

A

Short
water
ketamine

187
Q

Succinylcholine
Muscle relaxant of choice for RSI of general anesthesia
1-1.5 mg/kg = Ideal intubating conditions in about 45 seconds
Highly ______, ______ soluble, small amounts cross placenta
Very large doses (10 mg/kg) required to lead to _____ _____ sufficient to cause neonatal weakness
Rapidly metabolized by _________ (decreased in pregnancy)

A

ionized, water
placental transfer
pseudocholinesterase

188
Q

Rocuronium
Suitable alternative for RSI
0.6 mg/kg = ideal intubating conditions in about ____ ______
No impact on _____ ____

A

79 seconds
Apgar scores

189
Q

Vecuronium

A

0.1 mg/kg Slower onset (144 seconds)

190
Q

Atricurium
Less desirable agent for RSI because of ____ _____ required
May result in significant ______ release and hypotension

A

high doses
histamine

191
Q

Nitrous Oxide
_____ effect on maternal blood pressure
Minimal effect on uterine _____
Allows for reduction in use of halogenated agents
50-67% nitrous alone => awareness in 12-26% of cases
Transferred rapidly across the placenta
Neonates exposed to nitrous required more ______

A

Minimal
tone
resuscitation

192
Q

Volatile Agents
Decreased uterine tone
Oxytocin induced contractions completely _____ at ___ _____
Decreased (28%) MAC
Return to normal by 72 hours post partum

A

inhibited at 2 MAC

193
Q

Opioids
All cross the placenta, especially high _______ solubility
Usually avoid until after delivery
Meperidine’s active metabolite _________________ can accumulate in the mother and neonate resulting in respiratory and neurobehavioral alterations

A

lipid
normeperidine

194
Q

Few reports of malignant hyperthermia during pregnancy
The rarity of MH events in pregnancy suggests pregnancy _____ _____ the occurrence of MH

A

protects against

195
Q

MH is an ________ __________ _________ gene

A

inherited autosomal dominant

196
Q

All anesthetic agents ____ the _____

A

cross
placenta

197
Q

Cesarean delivery is a major abdominal surgical procedure
May go to PACU, patient’s room, or somewhere else
_____ _____ _____ has been cited as a recurring factor in maternal deaths

A

Inadequate postoperative care

198
Q

“Appropriate equipment and personnel should be available for obstetric patients recovering from major _____ or ______ anesthesia.”

A

neuraxial or general

199
Q

Oral intake – early intake (4-8 hours) associated with shorter time to return of ____ ____ and shorter hospital stay

A

bowel sounds

200
Q

Urinary catheter
No differences for general vs neuraxial
Risk factors for urinary retention:

A

Post op opioid analgesia (especially epidural)
Multiple gestation
Low BMI

201
Q

Anesthesia Complications

_____ & ______
Avoidance of sedative premedication
Deliberate low volatile concentration
Use of muscle relaxants
Reduced anesthetic doses in hypotension or hemorrhage
Conversion to general after failed neuraxial technique
Mistaken assumption that high baseline sympathetic tone is responsible for intraoperative tachycardia

A

Awareness and Recall

202
Q

Dyspnea
Hypo______ of brainstem
Blunted thoracic ______
Position

A

perfusion
proprioception

203
Q

Anesthesia Complications

Hypo______
Severe preeclampsia
IV fluids
Vasopressors

A

tension

204
Q

Anesthesia Complications

Neuraxial blockade _____
4-14% of epidurals
0.5-4% of spinals

A

failure

205
Q

Anesthesia Complications

High neuraxial blockade
Impaired ______
Unconsiousness
Respiratory depression
______cardia
Hypotension

A

phonation
Brady

206
Q

Anesthesia Complications

____ and _____
Hypotension
Uterotonic agents, ergot alkaloids
Surgical stimuli

A

Nausea and vomiting

207
Q

Anesthesia Complications

perioperative _____

A

pain

208
Q

Anesthesia Complications

Pruritus
___-____% incidence
More common intrathecally than epidurally
Not an _____

A

30-100
allergy

209
Q

Anesthesia Complications

Hypothermia and shivering
66 and 85% incidence respectively
Spinal reduces ____ ____ more rapidly than epidural
Shivering incidence similar but less severe in spinal group
______ improves for epidural, but not spinal

A

core temp
Prewarming

210
Q

Obstetric Complications

_____ _____
Leading cause of maternal and fetal morbidity and mortality worldwide

A

Postpartum Hemorrhage

211
Q

Obstetric Complications

_____ _____
More common with c-section
High parity
Overdistended uterus (multiple gestation, polyhydramnios, macrosomia)
Prolonged labor (augmented by oxytocin)
Chorioamnionitis
Abnormal placentation
Retained placental tissue
Poor perfusion of the uterine myometrium (hypotension)

A

Uterine atony

212
Q

Obstetric Complications

Obstetric _______
0.03-0.33% incidence
High risk procedure
GU injuries are common

A

hysterectomy

213
Q

Obstetric Complications

_________ ________
Operative delivery
Physiologic changes of pregnancy
History
Highest risk in first week postpartum
Prophylaxis?
Hydration
Early mobilization
Pneumatic compression devices
Pharmacologic prophylaxis in high risk patients

A

Thromboembolic events

NUNA 693 Obs/Regional (13 decks)

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