OB Lecture 2 Complications Flashcards
What is the most common cause of postpartum maternal palsy?
Cephalopelvic disproportion (big head, little pelvis) which results in lumbosacral trunk compression as it crosses pelvic brim by the fetal head.
How many parturients describe a backache?
75%, new onset for 60%
What are some reasons for backache?
- Inc. lumbar lordosis to counterbalance growing uterus.
* Inc. laxity of sacrococcygeal, sacroiliac, pubic joints.
What are some complications of neuraxial block?
Nerve injury —Epidural Hematoma —Epidural Abscess —Chemical nerve injury —Needle trauma —Positioning injury PDPH High or total spinal
This is a rare complication to neuraxial block and usually occurs in pts with hemostatic abnormality or coagulability
Epidural Hematoma
T/F: Epidural hematomas can only occur with block placement
False, can occur with catheter removal as well
What are some things that need checked if a patient has pregnancy induced HTN and you would like to place a block
Plt count >100K
Normal PT and PTT
How long do you avoid a neuraxial block with a therapeutically anticoagulated pt with LMWH
24 hours
How long do you avoid a neuraxial block with a prophylactically anticoagulated pt with LMWH
12 hours
When can you remove an epidural catheter when patients are on LMWH?
At least 12 hours after last dose
T/F: it is safe to administer a dose of LMWH an hour after a block has been placed
False must wait 2-4 hours after
Signs and symptoms of an epidural hematoma
- Bilateral leg weakness
- Incontinence
- Absent rectal sphincter tone
- Back pain
What do you do if you suspect an epidural hematoma?
CT or MRI, surgical decompression must occur within 6 hours for full neurological recovery to occur
How long does it take for symptoms to occur if you have an epidural abscess?
4-10 days, usually pain and loss of function
How do you treat an epidural abscess?
ABX and laminectomy, you have a 6-12 hour window before permanent damage occurs
What is the presentation of an epidural abscess?
• Severe back pain
—Worse with flexion; sometimes with radiation
• Exquisite local tenderness
• Fever, malaise, meningitis-like headache with neck stiffness
What are the lab value changes with an epidural abscess?
—Inc. WBC, inc. ESR, positive blood culture
Why is the epidural space very resistant to toxicity?
- Very vascular
- Intact membrane between it and the subarachnoid space
What is transient neurological symptoms?
• Pain and dysesthesia in buttocks, legs or calves that can follow SAB, resolves w/in 72 hrs
What is TNS most commonly caused by?
Lidocaine
How long does it take for compression injuries to heal?
2-6 days if mild, 2-3 years if severe
What is postpartum foot drop caused by?
Either common peroneal nerve from stirrups or brow compression of lumbosacral trunk
What is femoral or obturator neuropathy caused by?
–25% bilateral lithotomy of fetal head compression
What s/s do you have if you have a femoral nerve injury?
Difficulty climbing stairs
What s/s do you have if you have an obturator nerve injury?
Decreased sensation over upper inner thigh, weak hip adduction
What is the onset and duration of a PDPH?
Onset: 12-48 hours
Duration: Few days to weeks
What are the principle determinants of a PDPH?
Size of dura hole and type of needle used
T/F: Larger gauge and cutting edge needles increase PDPH incidence
True
What is the normal CSF volume and how much CSF is made per day?
Normal volume 150 cc
450 cc made/day
How much CSF fluid needs to be lost in order to create a PDPH?
As little as 20 cc
What is a PDPH caused by?
Sagging of intracranial contents and stretching of the pain sensitive tissues when the patient assumes an upright posture.
What can you encourage your patient to do to help with a PDPH
Caffeine intake, will help vasoconstrict blood vessels in brain
What are the PDPH risk factors?
- Younger age
- Larger needle gauge
- Cutting-edge Quincke spinal needle
- Cephalad or caudal orientation of Quincke needle
- History of PDPH or migraines.
What are the risk factors for dural puncture with an epidural needle?
Experience
Loss of resistance technique
Fatigue and haste
Accuracy of audit
Which needle has the highest risk for a PDPH?
16-18 g epidural
What is the hallmark sign of a PDPH?
Head pain when patient sitting or standing that is completely or almost completely relieved by recumbence
What is a pneumocephalus?
Seen with LOR to air that injects intrathecal, headache almost instant and of short duration (hours).
What is the most common cause of a perioperative HA?
Caffeine withdrawal
What is a cortical vein thrombosis?
Rare, throbbing HA, not relieved by bed rest, may have SZ, diagnosed by CT or MRI, no clear treatment beyond symptomatic mgmt
What are some other causes of HA besides a PDPH?
Sinusitis Caffeine withdrawal Migraine Meningitis Cortical vein thrombosis SAH SDH Tension HA Pneumocephalus
Can a PDPH cause permanent impairment?
Yes
What is some non-invasive treatment of a PDPH
Bedrest IV hydration ABD binder/compression PO/IV/epidural analgesics Cerebral vasoconstrictors ACTH
What is an epidural blood patch?
—Epidural space is identified and 15-20 cc of the patient’s own blood is injected (in strict aseptic manner) into the epidural space. Start slow and stop either when patient says headache is gone or they have a pressure sensation in the ears.
How often does an epidural blood patch work?
80%
90% effective on the 2nd try
What are the risks for an epidural blood patch?
Same as with regular epidural, has a higher incidence of backache. Risk of infection very rare but of theoretical concern.
What is a prophylactic blood patch?
Given prophylactically through epidural catheter. HA incidence of 10-21%
Controversial
25% do prophylactic blood patch
How does an EBP work?
- Clotting factors in blood help seal the hole in the dura
- The mass effect of the blood compresses the CSF giving nearly instant relief
- Try to inject at the same level as the initial dural puncture. Blood will spread a few levels however.
Total anesthesia involves what?
—Hypotension
—Dyspnea
—Aphonia
What are some causes of a total spinal?
—Migrated epidural catheter
—Unrecognized dural puncture
—SAB after failed epidural
What is the management of a total spinal?
- Place patient in LUD and Trendelenberg
- Early resuscitation, ventilation, and circulatory support.
- Epinephrine may be needed
- Naloxone for intraspinal opioid.
- Intensive maternal monitoring.
- Intensive fetal monitoring.
- Maintain maternal sedation.
- Possibly an urgent c-section
What are some s/s of aspiration?
—Hypoxia
—Pulmonary edema
—Bronchospasm
How do you prevent aspiration?
Cricoid pressure NPO Sodium citrate H2 blockers Reglan
How do you manage aspiration?
- Intubation and positive pressure ventilation w/ PEEP. Use only enough O2 to maintain O2 saturation in the 90s (high FiO2 may exacerbate lung injury)
- Suction as much as possible from airway.
- Rigid bronchoscopy only used when large food debris needs to be removed.
- Prophylactic antibiotics are controversial, may be detrimental.
- Prophylactic steroids have no role.
- Lavage is not routinely recommended.
- Patients may become hypovolemic through fluid shifts
