Operative Delivery Part 2 Flashcards by Carlos Valerio

What are the cons of preloading crystalloids prior to neuraxial anesthesia?

Rapid redistribution of crystalloids (20-30 mins)
-may redistribute by the time Neuraxial anesthesia adminstered.

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Which colloid has an increased risk for anaphylaxis?

Hetastarch
-a synthetic colloid
-also expensive

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What is the IM dose of ephedrine for hypotension?

25mg (can give up to 50 mg)

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What are some of the risks associated with ephedrine use before delivery?

Ephedrine readily crosses placenta and can cause:
-Umbilical artery Metabolic Acidosis
-Maternal reactive hypertension

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Which of the following readily crosses the placenta:
Ephedrine
Phenylephrine

Ephedrine

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Hyperbaric Lidocaine (5%) is not commonly used for spinal anesthesia due to risk of ____.

TNS
Transient Neurologic Syndrome (leg & back pain 24-48 hrs after spinal).

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We want our spinal anesthetic to reach what sensory level?

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What is the most common local anesthetic used for spinals?

0.75% bupivacaine

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What are the benefits of intrathecal opioids?

-improve block quality
-↓ intraoperative N/V
-↓ LA dose
-Prolongs postop analgesia

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How do intrathecal opioids decrease intraoperative N/V?

Opioids may decrease some of the sensations that trigger N/V.

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Is it safe to give combination of opioids intrathecally?

Yes.
-fentanyl (rapid onset/offset) with duramorph (long onset/duration) is commonly used.

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What is the dose of Fentanyl for SAB?

10 - 25mcg

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What are the side effects of intrathecal fentanyl?

Early respiratory depression
Pruritis

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What is the drug profile of fentanyl? How effective is spinal fentanyl?

Rapid onset (lipophilic)
Short duration of action

Excellent for intraop pain relief
Not as good for postop pain relief

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What is the dose of morphine for SAB?

100 - 150mcg

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What is the onset and duration for morphine administered intrathecally?

Onset: 30 - 60 min
Duration: 12 - 24 hrs

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Will respiratory depression be seen earlier or later with morphine administered via SAB?

Later (6-18 hrs after!)

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How long can pruritis from duramorph last? What is the treatment for duramorph associated pruritis?

Can last 12-24 hours (same as analgesic effect)
Treatment:
-Nalbuphine or Butorphanol
-Naloxone or Naltrexone
Benadryl won’t help, instead will make patient sleepy

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What is the dose of epinephrine as an adjunct to spinal anesthesia? How does this affect the block duration?

0.1 - 0.2mg epinephrine administered in a SAB.
Can prolong block by 15% or more
-due to alpha 2 adrenergic action of epi

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What dose of Precedex is utilized in spinals?

5-10 mcg

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What is the purpose of spinally administered Precedex?

Prolongs sensory & motor blockade
Post-op pain control
Minimizes shivering

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What are the adverse effects associated with spinally administered dexmedetomidine?

Bradycardia & Hypotension

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Epidural medication doses are approximately _____ times that of spinal doses.

5 - 10 x

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Are spinals or epidurals better for C-sections?

Spinals (more reliable and dense)

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What are some interventions for patients with epidural in place who are requiring unplanned c-section?

IV anesthetics such as ______ or ______ are commonly used as adjuncts to epidurals for patients undergoing unplanned c-section. Why are these medications utilized?

ketamine ; precedex

2% Lidocaine is just as fast as chloroprocaine when what is added to it?

Na⁺ Bicarbonate -2 mL added to 18 mL 2% lidocaine in 20 mL syringe

What are two rapid acting local anesthetics that may be used for an epidural dose up when converting to c section?

2% lidocaine 2-chloroprocaine 2-3%

How is chloroprocaine metabolized?

Pseudocholinesterases

What drug can decrease the efficacy of epidural morphine? Why?

2-Chloroprocaine Antagonizes μ and κ opioid receptors

What is the general onset and duration of bupivacaine? What risk is associated with bupivacaine?

Onset: intermediate Duration: long duration of action Risk: cardiac toxicity (more toxic than ropivacaine)

What dosage of bupivacaine is used for epidurals? What dose must be avoided in epidurals?

Epidural dose: 0.5% Not used in Epdirual: 0.75% -Only used in spinals

What dosage of ropivacaine is common for epidurals?

0.5%

What is the general onset and duration of ropivacaine? Compare the cardiac toxicity profiles of ropivacaine & bupivacaine?

Onset: intermediate Duration: long duration of action Ropivacaine is less cardiotoxic than bupivacaine

What is the dose and efficacy of epidural fentanyl? What are the side effects?

Between fentanyl and morphine, which opioid administered spinally provides for a more dense block?

Fentanyl

What is the dose and efficacy of epidural morphine? What are the side effects?

What ratio of dexmedetomidine to LA is typically used in epidurals? What are the potential risks associated with epidural dexmedetomidine?

4-5 mcg/mL of precedex for each 1mL of LA. -Ex. 20mL of LA + 80 - 100mcg Precedex Risks: -maternal bradycardia and HoTN -start with lower dose and see how patient responds

How does Na⁺ bicarb helps speed up onset?

Shifts local anesthetic to more **non-ionized state**. very useful speeding up epidural to avoid GETA.

# Converting from labor analgesia → surgical anesthesia Your patient has an epidural in place and is being converted from a normal labor to a c-section. The epidural is unilateral, how can this be fixed?

Replaced the catheter if possible

# Converting from labor analgesia → surgical anesthesia Your patient has an epidural in place and is being converted from a normal labor to a c-section. The epidural is patchy, how can this be fixed?

How much local anesthetic will you typically use to "top off" an epidural for a c-section?

10 - 15mls

What is the Allis Test?

Pinch patient with clamps to assess quality of epidural anesthesia. - If the patient can't feel clamps then you're good for surgical incision.

What are some dosing considerations for combined spinal epidural (CSE) ?

What are 4 reasons that one might have to convert to general anesthesia for a c-section?

- Fetal Distress (sustained fetal bradycardia) - Maternal Hemmorrhage w/ hypovolemia - Neuraxial Anesthetic not possible - Failed block/patient not tolerating

What are some reasons that neuraxial anesthesia may not be possible for c-section patients?

- Outright refusal - Infection - Coagulopathy / thrombocytopenia

What are the benefits of GETA?

Rapid onset Secured airway Hemodynamic stability

What are the disadvantages of GETA?

How does GETA affect 1-minute apgar scores?

↓ 1-minute Apgar score associated with GETA

Why is there a higher incidence of recall after GETA for delivery?

- no preop versed - ↓ MAC for delivery (due to loss of uterine tone & concurrent bleeding)

What is the dose of succinylcholine?

1 - 1.5 mg/kg -better to Overdose the succinylcholine than underdose it

What induction agents are used for emergent c-sections?

Propofol + Succ

What size ETT is used for c-sections?

6 - 7 mm ETT (remember that airway is friable & edematous)

What other tube is placed (other than ETT) for a GETA c-section?

orogastric tube (suction out the stomach)

In regards to a c-section delivery, when is pitocin/oxytocin started?

**AFTER** delivery *Needs to be announced to whole room that its being started*.

Less VAA = _______ uterine tone.

increased (results in less bleeding)

What is MAC value decreased to after delivery of the baby?

0.5 - 0.75 MAC

Opioids are given ____ delivery in order to decrease risk of neonate respiratory depression.

**After**.

What paralytic is used after Succinylcholine has worn off? What are some important considerations when administering non-depolarizing NMBD after succinylcholine?

Not often required with adequate depth of anesthesia -can increase VAA after delivery Magnesium infusion potentiates NMBD **Alway check twitches after succinylcholine and before adding Non-depolarizers** -pseudocholinesterase deficiency can occur with pregnancy

Maternal hypocapnia results in what oxygenation change for the fetus?

↓ O₂ delivery due to leftward oxyhemoglobin dissociation curve shift.

Maternal hypercapnia results in bradycardia or tachycardia?

Tachycardia

What would cause you to do a deep extubation on a parturient patient?

*Trick Question*. Extubate patient awake. Still considered a full stomach.

What are the three drugs used to treat uterine atony?

- Pitocin - Methergine (methylergonovine) - Hemabate (Carboprost)

What symptoms from a Pitocin drip would prompt you to slow the infusion?

Hypotension & flushing

When is Pitocin started after delivery? What dosage is used?

- After umbilical cord is cut - 20u in NS bag (drip in slowly)

What is the dose of Methergine (methylergonovine)?

0.2 mg IV/IM

________ would cause one to be very careful using Methergine (methylergonovine).

Hypertension

What is the dose of Carboprost (Hemabate)?

250mcg IM

What drug is given if a patient is still bleeding after Pitocin administration?

Carboprost (Hemabate)

What medical condition would make you cautious in giving Hemabate?

Asthma

What factors associated with C-sections result in PONV?

- Hypotension - Surgical Stimulation - Uterotonics

How does hypotension result in PONV?

- Cerebral hypoperfusion → medullary vomiting center stimulation - Gut ischemia → emetogenic substances released from intestines

Why does surgical stimulation result in PONV?

VAGAL Stimulation - Uterine exteriorization - Intra-abdominal manipulation - Periotneal tract stimulation

GETA for emergent c-section results in a very high risk for ______.

recall / hemorrhage

What drug can be given to help prevent recall in emergent c-sections? When is this given?

2mg Midazolam **as soon as the baby is out**.

Is it better to have block that is too high or too low?

too high *Can supplement w/ O₂*

What should anesthesia do if a block is excessively high? (loss of consciousness, loss of respiratory drive, refractory HoTN)

Convert to GETA