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SU 17: Grape Varieties > OB lecture 4: Surgery in the Parturient > Flashcards

OB lecture 4: Surgery in the Parturient Flashcards

1
Q

Common indications for Cesarean Section delivery:

A
  • Failure to progress (cervix not dilating)
  • Fetal distress (late decelerations)
  • Fetal Malpresentation
  • Previous C/S (or failed VBAC)
  • Maternal condition making vaginal delivery unsafe (HIV/genital herpes) disease prevention
  • Fetal condition making vaginal delivery unsafe (Cord Accident)
  • Multiples (twins +)
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2
Q

Regional anesthesia is the most common type of anesthesia in laboring parturients BC:

A
  • Safer than general Anes. lower maternal mortality
  • Most patients already have an epidural catheter in place when c section is called
  • there is less neonatal depression with regional anes
  • the mother is awake a able to witness the birth of her child.
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3
Q

Indications for general anesthesia for Cesarean Section:

A
  • Acute, severe fetal distress with no time for block
  • Epidural catheter failure
  • Parturient has contraindication to regional block
  • Regional block inadequate
  • Patient refusal to regional block
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4
Q

Advantages of GA for C section:

A
  • Proven track record of safety (still regional is safer)

- Produces rapid, reproducible conditions for delivery.

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5
Q

Disadvantages of GA for C section:

A
  • Still not as safe as regional (airway considerations)
  • forces you to deal with potentially difficult airway often under suboptimal, rushed conditions
  • Failed intubation
  • failed ventilation causing death or neurological injury.
  • Awareness
  • Aspiration PNA
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6
Q

What are the effects of anesthesia on the fetus?

A
  • Infants exposed to GA have lower Apgar scores at 1 minute after delivery, but no difference at 5 minutes after delivery.
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7
Q

During GA, one should limit time between uterine incision and delivery to less than ___ minutes.

A

3

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8
Q

What are some anatomic predictors of difficult airway in the parturient?

A
  • Mallampati 4
  • Receding Mandible
  • protruding incisors
  • mallampati 3
  • short neck
  • MP 2
  • MP 1

Obesity alone places the patient as risk for difficult airway.

(listed in order of most to least predictive)

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9
Q

Ways to avoid/prepare for anticipated difficult airway in parturient:

A
  • Place epidural catheter early and make sure it is working.
  • Have a plan in place: identify pt with potentially difficult airway. assemble additional equipment (McGrath, Glidescope), and experienced personnel.
  • Consider awake FOB if not stat c section and regional is not an option.
  • use short handle for intubation.
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10
Q

Aspiration Prophylaxis:

What antacid is most commonly used?

A

Sodium Citrate (sour tasting liquid)

used to raise gastric pH. May last only 15 minutes. Should be given to all puts prior to C/S (general or regional).

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11
Q

Aspiration Prophylaxis:

What 3 medications are commonly used for aspiration prophylaxis?

A
  1. Sodium Citrate
  2. Ranitidine (Zantac)
  3. Metoclopramide (Reglan)
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12
Q

What is the mechanism of action for Ranitidine (zantac) for aspiration prophylaxis?

A

Ranitidine (zantac): H2 blocker, usually used in addition to antacid as it does nothing for acid that is already present.

50mg IV dose

Max effect seen 2 hours after administration.

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13
Q

What is the mechanism of action for metoclopramide (Reglan) for aspiration prophylaxis?

A

Metoclopramide (Reglan): decreases gastric volume within minutes of administration, increases peristalsis. May have antiemetic effects. Effects are inhibited by opioids. May cause extra pyramidal side effects (agitation, restlessness, anxiety, tremor)

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14
Q

Patients for elective C/S or other procedures should be NPO for ___ hours at minimum, ___ hours preferable.

A

6 hours, but 8 hours preferably.

Although still at high risk for aspiration regardless.

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15
Q

To avoid compression of the IVC, Parturients should be positioned onto which side?

A

L lateral (decubitus), slightly on to L side to shift wt to R side and avoid IVC compression.

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16
Q

At term, O2 consumption increases ___-___% and FRC _____, what are the consequences of these 2 maternal changes?

A

Increases 20-30%
FRC decreases

This will result in a faster rate of desaturation during apnea.

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17
Q

Induction agents:

Propofol Dose:

Fetal effects:

Does it cross the placenta?

A

Propofol dose: 2-2.8 mg/kg

Fetal effects: minimal if any (does not appear to significantly change apgar score

Yes: propofol crosses the placenta as does Thiopental (no longer used)

18
Q

Induction Agents:

Ketamine dose:

When is it particularly useful to use?

Side effects:

A

Ketamine dose: 1-1.5mg/kg

Useful in the face of maternal hemorrhage as it supports BP, also decreased risk of bronchospasm

SE: hypertension, dysphoria,

19
Q

Are Benzodiazepines ok to give to parturient?

A

Midazolam causes more neonatal depression than other agents.

Benzodiazepines as a general class of drugs should be avoided as they have been linked to congenital anomalies. Weeks 3-8 of fetal development are most critical when organogenesis occurs.

20
Q

Induction Agents:

Etomidate

A

Generally avoided, may cause transient adrenal suppression in the neonate.

21
Q

Rapid sequence induction is _____ in all but the rarest cases. Why?

A

Mandatory

d/t all term parturients being considered a full stomach

22
Q

What muscle relaxants are safe to use in parturient?

A

All are safe as their hydrophilic charged nature significantly limits placental transfer.

There have been rare cases of neonatal paralysis in infants with homozygous atypical pseudocholinesterase.

23
Q

If an epidural or spinal block reaches what ___-___ dermatomes, a reduction in HR and contractiltilty may be seen. These nerve fibers are considered the cardiac accelerators.

A

T1-T4

24
Q

A sensory block above ___ often gives patients a sense of dyspnea, reassurance is helpful. At what dermatome would a patient experience paralysis of the diaphragm?

A

T2

C-3,4,5 innervate the diaphragm. testing grips can help a practitioner determine if the block has reached the diaphragm.

25
Q

_____ added to lidocaine or 2-chloroprocaine will speed up the onset of epidural block.

A

Sodium Bicarbonate

26
Q

The ideal block height for epidural or spinal is ____.

A

T4 (nipple line -T8 inferior rib line)

27
Q

__-__% of patient have breakthrough pain with epidural during C/S.

A

10-50%

Tx options:

  • bolus of LA
  • epidural or IV fentanyl
  • nitrous oxide
  • ketamine IV (keep total dose below 1mg/kg ~10mg at a time)
  • ask the surgeon to infiltrate with some local
  • if epidural is clearly inadequate, convert to GA.
28
Q

Spinal for C/S: Advantages over Epidural

A
  • Extensive, dense block with a single injection
  • Defined end point-if you get CSF flow, you’re in the correct spot.
  • Intravascular injection is not a concern
  • Technically simple, usually quick, does not involve placing a catheter.
29
Q

Disadvantages of spinal over Epidural anesthesia for c/s

A
  • finite duration- cannot redose
  • Risk of postural puncture headache (you have to puncture the dura)
  • Risk of total spinal (actually a risk of both techniques, but rare)
  • Maternal hypotension is more common.
30
Q

Laboring women have ____ hypotension with spinals than non-laboring patients.

A

LESS

Possible reasons: laboring patients have been receiving good IV hydration; descent of the fetal head into the pelvis may reduce aortocaval compression.

31
Q

Prehydration has a ____ ability to prevent hypotension.

A

LIMITED

  • cyrstalloids stay in intravascular space for about 20 minutes.
  • increased plasma volume = increased ANP (Atrial Natriuretic Peptide) production = diuresis
32
Q

_____ is considered the drug of choice for treatment of hypotension related to spinal/epidural anesthesia.

A

PHENYLEPHRINE

Ephedrine has been found to increase likelihood of fetal acidosis.

33
Q

_____ is the most commonly used LA in spinal/epidural anesthesia, why?

A

BUPIVACAINE (hyperbaric)

combines quick onset with intermediate duration

Other contenders/choices:

TETRACAINE (hyperbaric): prolonged onset, LONG duration, unreliable.

LIDOCAINE (hyperbaric): short acting, reports of transient neuro symptoms.

34
Q

After baby is delivered, it is important to administer ____ via pump.

A

Pitocin to help the uterus to contract and prevent hemorrhage.

2-5u bolus (may see a transient drop in BP and nausea after initiation)

35
Q

Adding duramorph to epidural provides long acting analgesia (12+) hrs, but increases risk of:

A
  • delayed respiratory depression
  • nausea and pruritis.

pruritus can be treated with nubaine or narcan

36
Q

Maternal changes that alter response to anesthesia:

A
  • decreased MAC
  • increased sensitivity to neuraxial agents (local anesthetics)
  • decreased plasma cholinesterase
  • decreased protein binding (more free drug)
37
Q

Anesthetic agents deemed safe during pregnancy include:

A 
thiopental
morphine (duramorph)
meperidine
fentanyl
succinylcholine
all neuromuscular blockers
38
Q

Anesthetic management in the parturient should be directed toward:

A
  • avoiding Hypoxemia, hypotension, and acidosis
  • maintain PaCO2 in normal range for parturient. During pregnancy a woman has a compensated respiratory alkalosis. (pCO2 28-32)
  • minimize effects of aortocaval compression.
39
Q

In addition to standard monitoring, fetal HR and uterine activity should be monitored at ___weeks gestation and beyond.

A

20

40
Q

Nitrous Oxide can interfere with metabolism of _____?

A

B12

41
Q

Elective procedures should be postponed until ___ weeks after delivery.

A

6 weeks

42
Q

the physiological effects of pregnancy are usually well established by ___ weeks gestation.

A

20

SU 17: Grape Varieties (9 decks)

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