Test 1 Flashcards
(142 cards)
1
Q
WHO classification of Gestational Trophoblastic Diseases (8)
** She wants us to know 4 main ones **
But who is she kidding
A
- Choriocarcinoma **
- Hydatiform (partial or complete) **
- Invasive hydatiform mole **
- Placental site trophoblastic tumor **
- Trophoblastic lesions, miscellaneous
- Exaggerated placental site
- Placental site nodule and plaques
- Unclassified trophoblastic lesion
- *********CHIP accronym for first 4 ******
2
Q
compare half life of meperidine to its metabolite
A
- meperidine 2.5 - 3 hours
-
normeperidine 14 - 21 hours
- (x3 in neonate ~ 72 hours!)
3
Q
Risk factors for fever
A
- nulliparity
- prolonged rupture of membranes
- prolonged labor
4
Q
Issue encountered: prolonged block:
assess for what?
A
- nerve injury
-
Epidural hematoma
- Rule out if no back pain, unilateral block, regression of Sx
5
Q
sensory changes (diff swallowing, breathing) are common with which opioid
A
sufentanil
6
Q
informed consent: 3 elements must be present
A
- Threshold (ability to make decision)
- Information (risks discussed, etc)
- Consent (really? noo…)
7
Q
h-2 receptor antagonists
A
- ranitidine
- famotidine
8
Q
PPIs
A
- omeprazole (Prilosec, Prilosec OTC) one she mentioned
- lansoprazole (Prevacid, Prevacid IV, Prevacid 24-Hour)
- pantoprazole (Protonix)
9
Q
danger of excessive ventilation (c-section)
A
- dec CO2 = uteroplacental vasoconstriction & Left O2 diss curve shift = fetal hypoxia
- (I’m assumining it has to do with CO2 changes)
10
Q
dyspnea after neuraxial usually due to
A
- Hypotension - tx and should improve
others causes:
- blunted thoracic proprioception
- partial blockade of abd/intercostals
- supine position
11
Q
high spinal symptons
A
loss of
- ability to talk
- strong grips
- maintain O2 sats
12
Q
non-anesthetic NV causes
A
- surgical stimulus
- bleeding
- medication
- motion at end of surgery
13
Q
single most important factor in the decline of maternal mortality from pulm aspiration during labor and csec delivery
A
use of neuraxial analgesia/anesthesia
14
Q
shifting of uterus on stomach (where does stomach go)
A
- shift to left & posteriorly
- rotated to right
effects compromise of LES
15
Q
stomach produces this much acid per day and contain this enzyme
A
1500 mL/day
pepsin
16
Q
peak acid output
A
38 mmol/hr
17
Q
3 phases of digestion
A
- cephalic - chewing, tasting, smelling (vagal stim - inc secretions)
- gastric - starts at release of gastrin
- intestinal - food goes into small int
18
Q
prego hormone that relaxes musles and LES tone
A
progesterone
19
Q
alveolar exudate from aspiration contatin these.
A
“R&B Cafe”
- RBCs
- cellular debris
- albumin
- fibrin
- edema
20
Q
most common cause of maternal anesthetic death
A
asp pneumonitis
aka: Mendelson’s syndrome
21
Q
most common site of injury for asp pneumonia
A
RLL
22
Q
Prophylaxis of aspirations: factors predisposing to regurgitation
A
- OB patients (wow)
- emergency surgery
- difficult/fafiled intubation
- light anesthesia
- GERD
23
Q
principle factors for increasing aspiration in pregnant women are:
A
- difficult intubation
- decrease LES tone
24
Q
advantage of PPIs
A
- long DOA
- low toxicity
- potential to have low maternal fetal concentrations at delivery
25
Respiratory changes:
* FRC
* ERV
* Closing volume
* O2 needs increase by
Respiratory changes:
* FRC decreased by 20%
* ERV decreased by 25%
* Closing volume unchanged
* O2 needs increase by 60%
26
difficult laryngeal mask ventilation defined as
• inability **within 3 attempts** of device insertion to produce expired **VT \> 7ml/kg** (l**eak pressure \> 15-20 cm H2O pressure)**
27
During apnea, time to desaturation depends on: (3)
During apnea, time to desaturation depends on:
## Footnote
**1) amount of oxygen stored in lungs, tissues, & blood**
**2) mixed venous oxyhemoglobin saturation**
**3) presence of intrapulmonary shunting**
28
head ache etiology:
* mild to moderate
* 30 mins to 7 days duration
* bilateral
* nonpulsating
* not aggrevated by physical activity
tension h/a
29
head ache etiology:
* mod to severe
* 4 - 72 hours duration
* unilateral
* pulsating
* physical factors aggrevate
* w/ nausea, photophobia, phonophobia
migraine
30
head ache etiology:
* mild to mod
* + neck /shoulder pain
musculoskeletal
31
head ache etiology:
* HTN and or HELLP syndrome
* bilateral, pulsating aggrevated by physical activity
pre-eclampsia/eclampsia
(get ALT, AST, uric acid, plt, urine protein)
32
head ache etiology:
* h/a w/o typical features
* overshadowed by focal neuro signs and or altered LOC
subdural hematoma
| (CT, MRI)
33
head ache etiology:
* mod h/a
* + focal neuro signs and/or altered LOC
cerebral infarction/ischemia
| (CT, MRI - "string of beads")
34
head ache etiology:
* progressive
* nonpulsatile
* aggrevated by: coughing/strain
* + inc CSF pressure
* normal CSF chemistry
**Idiopathic intracranial HTN**
(pseudotumor cerbri/benign intracranial HTN)
(can do LP)
35
head ache etiology:
* late h/a
* constant
* bilatereal or unilateral
carotid artery dissection
(carotid US, MRA)
36
head ache etiology:
* no hx of dural trauma
* diffuse
* dull
* worsening within 15 min of sitting/standing
* neck stiff
* n/v
* tinnitis
* photophobia
* CSF opening pressure \< 60 mm H2O in sitting position
spontaneous intracranial hypotension
(LP, radioisotope cisternography, CT myelography)
37
head ache etiology:
* within 5 days of dura puncture
* worse \< 15 min of standing/sitting
* neck stiff
* tinnitis
* photophobia
* nausea
PDPH
| (exam, possible MRI)
38
head ache etiology:
* nonspecific ha
* postural component
* focal neuro signs
* seizures
cortical vein thrombosis
| (CT or MRI/A)
39
head ache etiology:
* rapid
* intense
* incapacitating
* unilateral
* nausea
* nuchal rigidity
* altere LOC
SAH
| (CT w/ contrast or MRI FLAIR sequence)
40
head ache etiology:
* severe
* diffuse
* acute or gradual onset
* possible focal sz/neuro deficits
posterior reversible (leuko) encephalopathy syndrome (PRES)
(MRI)
41
head ache etiology:
* progressive
* localized ha
* worse in morning
* aggravated by couging/strain
brain tumor
| (CT, MRI)
42
head ache etiology:
* frontal h/a
* + facial pain
* h/a + nasal obstruction
* purulent nasal discharge, anosmia and fever
sinusitis
| (CT, MRI, nasal endoscopy)
43
head ache etiology:
* most frequent symptom
* diffuse
* intensity inc with time
* + nausea, photophobia, malaise, fever
Meningitis
| (LP)
44
head ache etiology:
* mild to mod
* temporal w/ breast-feeding or breast engorgement
lactation h/a
45
head ache etiology:
* mild to mod
* assoc w/ zofran intake
ondasetron h/a
46
PDPH must include one the following sx (5)
* *Diagnosis must include one of the following*: May include:
* **neck stiffness**
* **tinnitus**
* **hypacusis *(hearing disturbance)***
* **photophobia**
* **nausea**
47
complications of PDPH
* immediate issues (ER, extended hostitalization, cant do ADLs)
* subdural hematoma
* dural sinus thrombosis
* diplopia or hearing loss
48
***Best Treatment for PDPH***
and other tx's
* ***Best Treatment for PDPH is PREVENTION***
* Posture: bedrest does not help *to prevent: recommendation is to still have patients ambulate early*
* Hydration: Little evidence to support
* Caffeine: No evidence to support
* Cosyntropin: one study showed significantly fewer PDPH; mechanism unknown
* Neuraxial opioids: 1 study showed reduction with epidural opioids; caution against routine use
* Intrathecal catheters: most studies do no find significant decrease in PDPH
* Prophylactic epidural/intrathecal saline *to increase CSF*: needs further study
* Prophylactic blood patch: reliable conclusions cannot be made
49
* Blood patch Contraindications: (4)
* Blood patch Contraindications:
* **known coagulopathy**
* **local cutaneous or untreated systemic infection**
* **increased ICP due to space-occupying lesion**
* **patient refusal**
50
Hip innervation
* flexion
* extension
* aBduction
* adduction
* medial rotation
* lateral rotation
Hip innervation
* flexion **L1-3** (L4 min)
* extension **L4-S2**
* aBduction **L5-S1**
* adduction **L2-4**
* medial rotation **L1-S1**
* lateral rotation **L5-S2**
51
Knee innervation
* flexion
* extension
Knee innervation
* flexion **L5-S2** (min L2-4)
* extension **L2-L4**
52
Ankle innervation
* dosriflexion
* plantar flexion
Ankle innervation
* dosriflexion **L4-L5**
* plantar flexion **S1-S2**
53
Big toe dorsiflexion innervation
**L4-S1**
54
Levator ani innvervation
**S2-S4**
55
Coccygeus innervation
**S4**
56
**which nerve injury**
* By fetal head at pelvic brim often due to cephalopelvic disproportion *(**Usually occurs with prolonged labor or difficult vaginal delivery)*
* Affects peroneal nerve *most often* ***Medial Nerve Fibers*** *that form* ***Peroneal Nerve***
* Weak ankle dorsiflexion (foot drop);
* Sensory involves L5 dermatome
**Compression of lumbosacral trunk**
* By fetal head at pelvic brim often due to cephalopelvic disproportion *(**Usually occurs with prolonged labor or difficult vaginal delivery)*
* Affects peroneal nerve *most often* ***Medial Nerve Fibers*** *that form* ***Peroneal Nerve***
* Weak ankle dorsiflexion (foot drop);
* Sensory involves L5 dermatome
57
which nerve injury
* Susceptible as it crosses brim of pelvis or in obturator canal
* Mother often experiences pain when damage occurs
* Weakness of hip adduction & internal rotation
* Sensory disturbance over thigh
*Can happen with both c-section and vaginal deliveries*
**Obturator Nerve Palsy**
* Susceptible as it crosses brim of pelvis or in obturator canal
* Mother often experiences pain when damage occurs
* Weakness of hip adduction & internal rotation
* Sensory disturbance over thigh
*Can happen with both c-section and vaginal deliveries*
58
**which nerve injury**
* Vulnerable to stretch injury as it passes beneath inguinal ligament
* Due to prolonged flexion, abduction, & external rotation of hips in 2nd stage labor
* Procedures conducted in excessive lithotomy position
* Patellar reflex diminished or absent
*Pts may walk satisfactory on level surface but have* *difficulty climbing stairs*
**Femoral nerve palsy**
* Vulnerable to stretch injury as it passes beneath inguinal ligament
* Due to prolonged flexion, abduction, & external rotation of hips in 2nd stage labor
* Procedures conducted in excessive lithotomy position
* Patellar reflex diminished or absent
*Pts may walk satisfactory on level surface but have* *difficulty climbing stairs*
59
**which nerve injury**
* Neuropathy of the lateral femoral cutaneous nerve (purely sensory)
* Most likely cause: entrapment of nerve as it *runs around the anterior superior iliac spine as it* passes through inguinal ligament
* Risk factors:
* abdominal mass
* retractors for pelvic surgery
* edema
* *extremely large uterus such as twins or triplets*
* Sx: numbness, tingling, burning, etc., of anterolateral thigh
*Condition is expected to resolve after delivery*
**Meralgia Paresthetica**
* Neuropathy of the lateral femoral cutaneous nerve (purely sensory)
* Most likely cause: entrapment of nerve as it *runs around the anterior superior iliac spine as it* passes through inguinal ligament
* Risk factors:
* abdominal mass
* retractors for pelvic surgery
* edema
* *extremely large uterus such as twins or triplets*
* Sx: numbness, tingling, burning, etc., of anterolateral thigh
*Condition is expected to resolve after delivery*
60
Significant causative factors of PP bladder dysfunction:
Significant causative factors of PP bladder dysfunction:
* **Prolonged 2nd stage of labor**
* **Instrumental delivery**
* **Perineal damage**
61
Space occupying lesions: Deficit depends on vertebral level location:
a. lower thoracic
b. lumbar
SOL: Deficit depends on vertebral level location:
1. **Low thoracic -\> leg weakness or paraplegia;**
2. **Lumbar -\> _cauda equina syndrome_; back pain radiating to legs is common**
62
* **Meningitis:** Causative organism:
1. **Meningitis**
1. Causative organism:
1. ***Neisseria meningitidis***
2. ***Streptococcus pneumoniae***
3. ***Haemophilus influenzae***
4. **also reported tuberculosis**
5. **viruses**
6. **![]()-hemolytic strep**
63
Meningitis Risk factors:
1. Meningitis Risk factors:
1. **dural puncture**
2. **labor**
3. **infection at a remote site**
4. **faulty technique**
64
RIsk factors for chemical damage to the Cauda Equina
* Poor spread of local
* block failure then repeated injections made
* fine gauge needle or pencil-point
* microspinal catheter
* continuous infusion
* hyperbaric soln
* lithotomy
* unintentional intrathecal inj with large epidural dose
* incorrect formulation with unsuitable preservative/antioxidant
* intrathecal inj of LIDOCAINE 5% (also tetracaine or dibucaine?)
65
1. ***Lawsuits against health care providers are primarily filed due to a lack of failure.***
1. Failures include: (4)
1. ***Lawsuits against health care providers are primarily filed due to a lack of failure.***
1. Failures include:
1. **Lack of informed consent**
2. **Poor patient rapport**
3. **Language barriers**
4. **Inadequate discharge instructions**
66
1. Theories of Liability
1. Patients may sue for injuries resulting from provision of health care using 1 or more of 3 different theories
1. Theories of Liability
1. Patients may sue for injuries resulting from provision of health care using 1 or more of 3 different theories
* **medical malpractice**
* **breach of contractual promise** that injury would not occur
* lack of **informed consent**
67
* **defined as “that degree of care, skill, & learning expected of a reasonably prudent health care provider at that time in the profession or class to which he/she belongs** …**acting on the same or similar circumstances”.**
Standard of care
68
Establishing medical malpractice: 4 elements required
* Establishing medical malpractice: 4 elements required
* **Duty**
* *Duty to provide care*
* **Breach**
* *Failed to meet duty to provide reasonable care*
* **Injury**
* **Proximate cause**
* *Negligence of provider proximately causing the injury*
69
**Doctrine of *res ipsa loquitur*** (means what??): and.. 3 conditions
**Doctrine of *res ipsa loquitur*** (the thing speaks for itself): 3 conditions
1) injury ordinarily does not occur in absence of negligence
2) injury caused by agency or instrumentality in exclusive control of defendant
3) injury not a result of any voluntary action or contribution on part of the plaintiff
70
* Lack of informed consent: (also cause for lawsuit)
* *Pt must prove:(4)*
Lack of informed consent: (also cause for lawsuit)
## Footnote
*Pt must prove:*
**1) existence of material & foreseeable risk unknown to patient**
**2) failure to inform plaintiff of that risk**
**3) disclosure of risk would have led to rejection of difference course of treatment**
**4) causal connection between failure to inform & injury resulting from occurrence of nondisclosed risk**
71
systemic diseases (autoimmune)
**Systemic Autoimmune**
\*if not on this list probably an 'organ-specific' autoimmune
* **SLE**
* **RA**
* **MS**
* **Sjogren's**
* **Dermatomyosis**
* **scleroderma**
* **polymyositis**
* **mixed connective tissue disease**
* **Wegener's granulomatosis**
72
* Dx criteria for SLE (need at least 4)
* 20% of SLE occurs during pregnancy
* Malar rash (butterfly over malar region)
* discoid rash (red, raised patches with scaling)
* photosensitive
* oral ulcers
* arthritis
* serositis (pleuritis/pericarditis)
* renal issues (protein/casts)
* neuro (sz, psychosis)
* hematologic (anemia, leukopenia, lypmphopenia, thrombocytopenia)
* immunogenic (anti-DNA, anti-Sm nuclear antigen, anticardiolipin, anticoagulant, false positive syphilis)
* antinuclear antibody
73
10 warning signs of LUPUS FLARE
1. aching, inc joint swell
2. weakness/pain in muscle
3. unusual high/frequent fever
4. inc fatigue/exhaustion
5. hair loss
6. h/a
7. dizzy/forgetful
8. abd pain/digestive issues
9. rash
10. new/unexplained symptom
74
**Antiphospholipid Syndrome (APS) *or Hughes Syndrome***
* Prothrombotic disorder characterized by presence of **2 autoantibodies:**
**Antiphospholipid Syndrome (APS) *or Hughes Syndrome***
* Prothrombotic disorder characterized by presence of 2 autoantibodies:
* **Lupus anticoagulant**
* **anticardiolipin antibody**
75
Describing which autoimmune dz?
* Chronic, progressive autoimmune disease of unknown etiology
* Characterized by:
* **deposition of fibrous connective tissues in skin & other tissues,**
* **microvascular changes**
* **chronic inflammation**
* *Limited or Diffuse process*
**Scleroderma**
* Chronic, progressive autoimmune disease of unknown etiology
* Characterized by **deposition of fibrous connective tissues in skin & other tissues, microvascular changes, & chronic inflammation**
* *Limited or Diffuse process*
76
Describes which autoimmune dz?
* Members of the disease group, idiopathic inflammatory myopathic disease
* characterized by nonsuppurative inflammation of muscle, primarily skeletal muscles of proximal limbs, neck, & pharynx
* Inflammation leads to *symmetric* weakness, atrophy, & fibrosis of affected muscles
* Can have heliotrope eruptions (blue-purple discoloration of upper eyelid) & Gottron’s papules (raised scaly, violet eruptions over knuckles)
* woman 2x \> men
**Polymyositis & dermatomyositis**
* Members of the disease group, idiopathic inflammatory myopathic disease
* **Polymyositis:** characterized by nonsuppurative inflammation of muscle, primarily **skeletal muscles of proximal limbs, neck, & pharynx**
* **Suppurative means the formation of pus.**
* Inflammation leads to *symmetric* weakness, atrophy, & fibrosis of affected muscles
* **Dermatomyositis:** same disorder with addition of **heliotrope eruption** (blue-purple discoloration of upper eyelid) & **Gottron’s papules (**raised scaly, violet eruptions over knuckles)
* woman 2x \> men
77
* Conditions predisposing women to aortic dissection during pregnancy
* Conditions predisposing women to aortic dissection during pregnancy
* **Marfan syndrome**
* **Ehlers-Danlos syndrome**
* **bicuspid aortic valve**
* **Turner syndrome**
* **non-Marfan syndrome-associated familial thoracic aneurysms**
78
Which cardio dz:
* autosomal dominant
* causes aortic dilation and dissection
* presence of valvular disease
Marfan
79
Which cardio dz:
* connective tissue dz
* TYPE 1,2,3 (explain)
* TYPE 4 (explain)
* **Ehlers-Danlos** – Connective tissue disease with varying degrees of severity
* **Types 1, 2, & 3** have more **pelvic instability**, **preterm** delivery, **perineal lacerations**, and **post-partum hemorrhage**
* **Type 4** at risk of **rupture of bowel, aorta, vena cava and uterus**
80
* **complete of partial absence of an X chromosome**
* assoc. with **aortic coarctation and HTN**
* **30% will have a bicuspid** aortic valve which is a risk for aortic dissection
***T*****urner’s Syndrome** – complete of partial absence of an X chromosome, assoc. with aortic coarctation and HTN, 30% will have a bicuspid aortic valve which is a risk for aortic dissection
81
name of condition in Marfan with widening of the dural sac usually in the lumbar sacral area - complicates neuraxial
**Dural ectasia**
(scoliosis complicates neuraxial in marfans too)
82
**Transposition of the great arteries**
* Divided into these two groups:
**Transposition of the great arteries**
* Those with transposition of the great arteries are divided into two groups:
* **D-Transposition:** Complete transposition of the great arteries
* **L-Transposition:** Congenitally corrected transposition of the great arteries
83
pulm HTN anesthetic considerations
pulm HTN anesthetic considerations
(VERY high risk group)
* **maintain SVR**
* **maintain PRELOAD**
* **Prevent/Tx**
* **pain**
* **acidosis, hypoxemia, hypercarbia**
* **avoid myocardial depression**
* **PA cath with fluoro better**
84
* **Primary goals of anesthesia in Eisenmenger Syndrome (5)**
**Primary goals of anesthesia:**
* 1) maintain **adequate SVR**
* 2) Maintain adequate intravascular volume & **venous return**
* 3) **avoid ACC**
* 4) prevention of **pain, hypoxemia, hypercarbia, & acidosis (*↑* PVR)**
* 5) **avoidance of myocardial depression**
85
* Most common cause of Aortic Stenosis in pregnant women is:
* Other less common causes:
* Most common cause of Aortic Stenosis in pregnant women is congenital **bicuspid aortic valve**
* Other less common causes:
* Rheumatic
* supravalvular AS
* subvalvular AS
86
type of AS that is unlikely in pregnancies
**Caclific AS**
* occur much later in life post childbearing
87
preferred delivery method in AS
vaginal
88
**Aortic Stenosis**
* Anesthetic Goals:
**Aortic Stenosis**
Anesthetic Goals:
* 1) maintain normal HR, NSR, and adequate SVR
* 2) maintain intravascular volume & venous return
* 3) avoidance of aortocaval compression
* 4) avoid myocardial depression during GA
89
gold standard anesethetic for severe AS
GA
90
Most common cause of AR
**degenerated bicuspid aortic valve**
91
most common cause of aucte AR
endocarditis
92
**Goals of anesthetic management in AR**
* **Goals of anesthetic management in AR:**
* 1) maintenance of normal to slightly elevated HR
* 2) prevention of an increase in SVR
* 3) avoidance of aortocaval compression
* 4) avoidance of myocardial depression during general anesthesia
93
Most commonly valvular disease in pregnancy
MS
94
MS: why is vaginal delivery assisted
avoids valsalva in 2nd stage bc may increase CVP
95
**Anesthetic goals for Mitral Stenosis:**
* **Anesthetic goals for Mitral Stenosis:**
* 1) maintenance of low-normal HR & preserve NSR
* 2) aggressive treatment of atrial fibrillation, if present
* 3) avoid aortocaval compression
* 4) maintenance of venous return
* 5) maintenance of adequate SVR
* 6) prevention of pain, hypoxemia, hypercarbia, & acidosis (can ![]() PVR)
96
DM: insulin resistance due to presumed mechanisms of inc counterregulatory hormones (4)
DM: insulin resistance due to presumed mechanisms of inc counterregulatory hormones (4)
* **placental lactogen**
* **placental growth hormone**
* **cortisol**
* **progesterone**
97
pre-gestational DM and insulin resistance
insulin requirements increase during pregnancy bc of increase in peripheral insulin resitance that already existed
## Footnote
**(so.. additive resistance when during pregnancy state)**
98
DM-1 insulin requirements during stages of labor 1 and 2
* Insulin requirements decrease with the onset of the 1st stage of labor
* Insulin requirements increase during 2nd stage of labor
99
* Both pregestational & gestational DM associated with higher rates of (3)
* Both pregestational & gestational DM associated with higher rates of
* **gestational HTN**
* **polyhydramnios**
* **cesarean delivery**
100
DM: fetal acidosis not likely if: (3)
DM: fetal acidosis
* Not likely if:
* 1) satisfactory maternal **glycemic contro**l;
* 2) **preanesthetic volume expansion** with non-dextrose balanced salt solutions
* 3) maintain **hemodynamic stability**
101
peripartum glucose level goal
70 - 90 mg/dL
102
may be the most significant sign for potential of diabetic stiff-joint syndrome leading to a difficult airway/intubation
Prayers Sign
103
Hyperthyroidism anesthetic managment
* **Anesthetic management**
* **Avoid** drugs that can cause **tachycardia (ketamine)**
* Need **glucocorticoid supplementation** (*hyperthyroidism causes* relative deficient body reserves *of glucocorticoid*)
* If **exophthalmic, be careful with eyes** during GA *(consider eye ointment in addition to taping of the eyes*)
* Be **prepared to treat perioperative thyroid storm**
104
Hypothyroidism associated with the following issues (7)
* **Anemia**
* **preeclampsia**
* **fetal growth restriction**
* **gestational diabetes**
* **preterm delivery**
* **placental abruption**
* **postpartum hemorrhage**
105
Clinical manifestations that affect anesthetic management in hypothyroidism
* Reversible myocardial dysfunction
* CAD
* reversible defects in hypoxic & hypercapnic ventilatory drives
* OSA
* paresthesias
* prolonged SSEPs
* abnormal peripheral nerve conduction
* increased peripheral nociceptive thresholds
* hyponatremia
* anemia
* abnormal coagulation factors & platelets
* decreased glucocorticoid reserves
106
preferred delivery choice in Pheo
C/S
107
PHEO: These drugs to avoid
may increase (direct/indirect) CAT release by tumor
* sux
* vanc
* morphine
* atracurium
* pancuronium
* droperidol
* glucocorticoids
* metochlopromide
* pentazocine
108
Hg less than this, consider other causes of anemia
\< 10.5 gm/dL
109
most common cause of anemia in pregnancy
IDA
110
Group of microcytic, hemolytic anemias resulting from reduced synthesis of 1 or more polypeptide globin chains
**Thalassemia**
111
* microcytic and hemolytic anemias in (Thalassemia) result from reduced synthesis of 1 or more polypeptide globin chains leads to the following:
**1.) Imbalance in globin chain ratios**
**2.) Defective hemoglobin**
**3.) RBC damage resulting from excess globin subunits**
112
**α-thalassemia (4 types):**
1. ) **Silent carrier** = no ↑ risk for pregnancy or surgery
2. ) **𝛼-thalassemia** = typically asymptomatic; no adverse outcomes for pregnancy or surgery
3. ) **Hemoglobin H disease** = moderately severe microcytic anemia, splenomegaly, fatigue & general discomfort
4. ) **Hemoglobin Barts** = generally incompatible with life
113
* this type of thalassemia has inc incidence of spontaneous abortions, intrauterine fetal death and fetal growth restriction
* unusual to see preganant
**β-thalassemia major**
114
this type of anemia has greater risk of oligohydramnios and fetal growth restrictions even though the clinical course is benign and tolerated well in pregnancy
**B-thalassemia minor**
115
most common abnormal Hg in SCA (sickle cell an.)
**Hg .. ("decks")**
* D
* E
* C
* S
116
* Sickle cell disease
* Disorders in which sickling results in clinical S&S (4)
**1.) Hgb SS disease**
**2.) Hgb SC disease**
**3.) Hgb SD disease**
**4.) Sickle cell β-thalassemia**
117
**most important factor in sickling**
and other factors
**O2 tension (i.e. PaO2)**
* Hg S \> 50% of total Hg
* dehydration (inc viscosity)
* hypotension (vascular stasis)
* hypothermia
* acidosis
118
preferred anesthesia choice in SCA
**NAA**
GA is acceptable too
119
Autoimmune thrombocytopenic purpura (ATP) preferred delivery
vaginal
\> 80k plt consider NAA
120
thrombotic thrombocytopenic purpura (TTP) and NAA implications
NAA NOT recommended - plt very low
121
meds/substances affecting hemostasis (several)
* ASA, NSAIDS (transient - NAA okay)
* LMWH, heparin
* **Dextran**
* **hydroxyethyl starch**
* **omega-3 fatty acids**
* Garlic, Ginsen, & Ginko
122
ASRA guideline on unfractionated heparin and NAA
Thrombophylaxis with twice-daily dosing of unfractionated heparin does not contraindicate use of neuraxial anesthesia as long as **total daily dose is NOT \> 10,000 units**
123
plt \> this amount is usually sufficient for safe NAA
**80,000/mm3**
124
most important factor to consider in thrombocytopenic pt
risk vs benefit of NAA
125
most important means of assessing the risk of epidural hematoma
(not in notes but in Chestnut)
**clinical judgement**
(wow that was hard, nevertheless, an eye opener)
126
**Following Factors to Consider in Thrombocytopenic Patient**
* 1) Clinical evidence of bleeding
* 2) Time interval since platelet count was measured
* 3) Any recent change in platelet count (e.g., downward trending)
* 4) Quality of platelet function
* 5) Adequacy of coagulation factor level & function
* 6) Risk vs benefit of performing neuraxial anesthesia
127
all pregnant women should be screen for which hepatitis
hep B
128
* 2 distinct areas of discomfort for back pain:
1) **lumbar spine area** (low back)
2) **posterior pelvic girdle area** (sacroiliac joints radiating into posterior thighs)
129
Scoliosis: Echo to assess right-sided heart function if one or more present
1) Curve of 60° or more;
2) Hypoxemia on ABGs;
3) ↓ predicted PFTs
4) Pulm HTN
130
scoliosis: most common ABG abnormality
Increased A-a O2 gradient
+
dec PaO2 & Normal PaCO2
131
Rheumatoid Arthritis (RA) - preferred delivery
vaginal delivery
132
most common cause of dwarfism
achondroplasia
| (inherited disorder of bone metabolism)
133
cord lesion location associated with autonomic hyperreflexia
**T6 or greater**
(NAA preferrered to blunt)
(epidural preferred - continuous titrate up)
134
**major disadvantage of dural puncture (with epidural) in someone with brain neoplasm who already had increased ICP**
**Fatal brain stem herniation**
135
anesthetic choice of technique for obese pregnant pt
NAA
136
Strategies for reducing risk for small airway closure, atelectasis & hypoxemia (5)
* **1) FiO2 \< 0.80**
* **2) TV 6-10 ml/Kg IBW**
* **3) RR maintain physiologic PaCO2**
* **4) manual or automated recruitment maneuver**
* **5) PEEP**
137
Renal
* K+ \> \_\_\_\_\_mEq/L recommend dialysis before elective procedure
* Sux will cause increase of _____ mEq/L rise in K+
* K+ \> **5.5** mEq/L recommend dialysis before elective procedure
* Sux will cause increase of **0.5-0.7** mEq/L rise in K+
138
Anesthetic Goals in asthmatics
1) provision of pain relief
2) reduction in stimulus to hyperpnea
3) prevention or relief of maternal stress
139
can do NAA on alcohol intoxication if: (4)
* 1) patient is **cooperative**
* 2) no evidence of **coagulopathy**
* 3) patient is **volume replete**
* 4) **baseline neurologic deficits are assessed & documented**
140
avoid these induction agents in cocaine abuse pt
* **ketamine**
* **etomidate** (precipitate myoclonus/hyperreflexia)
141
high doses of ecstacy (MDMA) may cause this
rhabdomyolosis
142
