Obstetric Airway Management

Question 0

What are the two major reasons that airway is a leading cause of anesthetic mortality

Answer 0

1) to secure a patient airway

2) Aspiration

Question 1

Anesthesia related obstetric mortality occurs in how many patients

Answer 1

1: 500,000 Pregnancies

Question 2

What are the risk associated with pregnancy and airways

Answer 2

1) Failure to Intubate
2) Aspiration
3) Hypoxemia
4) Urgency for two patients
5) Failure to prepare completely, I.e. plan A, B,C …

Question 3

True or false. NPO status eliminates risk of aspiration

Answer 3

False. It does not eliminate risk for aspiration

Question 4

In regards to aspiration what decreases gastric emptying? Increases gastric acidity?

Answer 4

Decreased gastric emptying

1) Progesterone
2) Stress of labor
3) Narcotics

Increase gastric acidity
1) Gastrin

Question 6

What factors decrease gastric emptying

Answer 6

1) Progesterone
2) stress of labor
3) narcotics

Question 7

What causes increases in gastric acid

Answer 7

Gastrin

Question 8

What causes decreased Gastro esophageal sphincter tone

Answer 8

1) Reflux patients
2) anticholinergics ( Impede tone)
3) narcotics
4) insertion and removal of NG tube (impacts competency of GE Junction)

Question 9

How does pregnancy effect gastric pressures

Answer 9

Single pregnancy, 7 –> 17 cmH2O

Twin pregnancy, 7 –> 40

Question 10

How does the lithotomy position Impact gastric Pressure

Answer 10

Single pregnancy, 17 –> 24 cmH2O

Question 11

What factors contribute to failure to Intubate

Answer 11

1) Upper airway edema
2) adiposity of Head, neck, and trunk
3) breast enlargement

Question 12

In comparison to non-gravid patients what is the failure to Intubate rate

Answer 12

10 fold. ( Actual number 1: 250)

Question 13

What are the contributing factors to hypoxemia during pregnancy

Answer 13

FRC decreases by 20% in pregnancy

VO2 (Oxygen consumption)
Increases by 20% in term
Increases by 60% in active labor

Question 14

In regards to your pre-op consult, how do you Identify the increased risks

Answer 14

1) Perform excellent airway history exam
2) asses head neck trunk breast when supine 3) assess ability to visualize upper airway
4) documented history exam and increase risk and discuss with patient family

Question 19

What are some causes of aspiration in the Obstetric patient

Answer 19

1) Decreased gastric emptying
2) Increased gastric acidity
3) Decreased gastroesophageal sphincter tone
4) Hiatal hernia (27%)
5) Increased gastric pressure
6) Failure to Intubate

Question 20

What causes of decreased gastric Emptying

Answer 20

1) Progesterone
2) Stress of labor
3) narcotics

Question 21

What are causes of increased gastric acidity

Answer 21

Gastrin

Question 22

Water causes of decreased gastroesophageal sphincter tone

Answer 22

1) Reflux patients
2) anitcholinergics (Impede tone)
3) narcotics
4) insertion and removal of NG tube (Effect competency of GE junction)

Question 23

How does pregnancy affect gastric pressures

Answer 23

Single fetus = 7 –> 17 cmH2O
Twin fetus = 7 –> 40

Lithotomy position impacts gastric pressure by increasing from 17 –> 40 cmH2O in single status (Obviously more in multiple fetus)

Question 24

What are contributing factors for failure Intubate

Answer 24

1) Upper airway edema
2) adiposity of head and neck and trunk
3) breast enlargement

Question 25

How does the gravid patient impact the rate of failure to Intubate

Answer 25

A 10 fold increase

Actual number: 1 in 250 failed

Question 26

What are the contributing factors to Hypoxemia during pregnant

Answer 26

FRC is decreased by 20%

V O2 (Oxygen consumption)
Increased by 20% in term
Increased by 60% in active labor

Question 27

In regards to anesthetic management how we manage the increased risk of The pregnant patient

Answer 27

1) Identify the risk
2) prevent acid reflux
3) identify single or multiple gestation
4) vigilant during Active labor

Question 28

What should the preop evaluation consistent of for the pregnant patient

Answer 28

1) Perform excellent airway history And exam
2) Assess head neck trunk breast when supine
3) assess ability to visualize upper airway
4) document the history exam and increase risk also discussed with patient and family

Question 29

In regards to aspiration prophylaxis what should be given preop

Answer 29

1) IV fluids
2) cimetidine 300 mg IV 60 minutes prior (H2 blocker - to inhibit gastric acid secretion
3) metoclopramide 10 mg IV 30 minutes prior (To increase gastric emptying)
4) sodium citrate 30 mL PO immediately prior (To increase pH, Neutralize gastric contents)

Question 30

In preparing plan A for the obstetric patient what are our goals

Answer 30

Prepare for first attempt success by:

1) Optimize patient positioning
2) provide complete the oxygenation
3) downsize ETT
4) utilize Sellick maneuver throughout
5) utilized ETT introducer if needed
6) move to plan B at predetermined endpoint

remember fetus is desaturating just like mom

Question 31

Ok… so what if you did have to move to plan B, what would you be doing?

Answer 31

1) Main goal is to oxygenate both patients
2) Continue Sellick maneuver
3) ventilate the patient

Question 32

What you had to go to plan C? then what?

Answer 32

Utilize HPOV v/s RGW. (For details see difficult airway cards)