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90 Cards in this Set

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James Young Simpson
1) 1st OB anesthetic
2) Ether
3) 1/19/1847
4) Chloroform
John Snow
1) 1st physician anesthetist
2) Chloroform
3) Queen Victoria
Nathan C. Keep
1) 1st OB anesthetic in U.S.
2) Ether
3) 4/7/1847
Crawford W. Long
1) Ether since 1842
2) wife's delivery 1847
1900 - 1940's
"twilight sleep"
scopolamine-morphine anesthesia
Duke inhalers
1) Cyprane
2) Penthrane
3) N2O & O2
1853
hypothermic needle
1878
cocaine
1884
Koller eye block
1885
Corning spinal anes.
1905
Einhorn - procaine
1908
Pudendal (anes.?)
1926
paracervical block
1928
1) spinal anes. OB
2) Dr. Cleland described pain pathways of uterine contraction
1940's
caudal blocks followed by epidurals
1943
Lidocaine
mean body weight
> 17 % or 12 kg during pregnancy
mean body weight: 1 kg
1) uterus - 1 kg
2) amniotic fluid - 1 kg
mean body weight: 2 kg
1) blood volume - 2 kg
2) interstitial fluid - 2 kg
mean body weight: 4 kg
1) fetus/placenta - 4 kg
2) new fat and protein - 4 kg
pulmonary change (anatomic)
1) diaphragm elevation
2) < FRC
3) capillary engorgement affects all airways
pulmonary change (physiologic)
1) > O2 consumption
2) > CO2 production
3) > alveolar ventilation
CV change (anatomic)
1) biventricular hypertrophy
2) cardiac elevation
3) leftward rotation
CV change (physiologic)
> CO
GI change (anatomic)
1) < cardioesophageal sphincter tone
2) horizontal gastric axis
GI change (physiologic)
1) > volume and acidity of gastric contents
2) > intragastric pressure
Urogenital change (anatomic)
1) hydronephrosis
2) hydroureter
3) > bladder capacity
4) urine stasis
urogenital change (physiologic)
1) > renal blood flow
2) > GFR
3) frequent UTIs
circulatory change (anatomic)
1) aortocaval compression
2) lower body venous stasis
circulatory change (physiologic)
1) expand blood volume
2) greater thromboembolic risks
3) > procoagulant activity
progenterone induces?
tracheal and bronchial dilation
ventilation
1) > min. ventilation 19-50% by term
2) > RR 9%
3) > TV 28%
4) progesterone resp. stimulant
5) CO2 sensitive
6) > O2 consumption 40-60%
oxyhemoglobin curve shifts to?
right
lobor:vent. data
1) > RR 22-70
2) > TV 650-2000 ml
3) > MV 9-30 L/M
4) < PaCO2 15-20 mmHg
5) PaO2 100-108 mm Hg
time until SAO2 falls to less than 90 %
1) ideal wt. - 364 sec.
2) obese - 247 sec.
3) morbid obesity - 163 sec.
maternal hyperventilation: fetal effects
1) constriction umbilical & uterine arteries
2) fetal acidosis
3) hypocapnia
4) maternal Hb dissociation curve to the left (meta. acidosis)
changes in blood volume and circulatory variables are a result of?
increased metabolic demand
CV >
1) > blood volume
2) > plasma volume
3) > RBC volume
4) > CO
5) > stroke volume
6) > HR
7) > femoral (uterine?) venous pressure
CV <
1) < total peripheral resistance
2) < MAP
3) < SBP
4) < DBP
CV: no change
1) CVP
blood volume
1) nonpregnant: 4,000 ml
2) pregnancy: 5,700 ml (+40%)
physiologic anemia of pregnancy is caused by?
reduced blood viscosity
1) > blood volume 35-50%
2) > plasma volume 45%
3) > RBC volume ONLY 20%
clinical implications of physiologic anemia
1) Hb should remain > 12 g%
2) > RBC mass = > O2 demands
3) blood loss is physiologically tolerated
4) > nutrient supply to fetal unit (> iron)
average blood loss at delivery
1) vaginal delivery: 300-500 ml
2) C-section: 500-1000 ml
ECG change
1) heart to the left
2) axis on ECG to left
3) minor nonspecific ST, T, Q wave changes
4) minor arrhythmias
2 components of the aortocaval compression phenomenon?
1) inferior vena cava compression
2) aortoiliac obstruction
Azygos vein/ paravertebral system
1) alternative circulation after 24 weeks gestation
2) by inferior vena cava compression
3) compensatory increase in sympathetic tone and HR
aortoiliac obstruction
1) arterial side compression
2) no maernal symptoms
3) placental blood flow decreases
4) femoral flow VS brachial flow
supine hypotensive syndrome
1) avoid supine position
2) syndrome more exaggerated with regional anesthesia
3) lower extremity stasis
4) epidural venous engorgement
5) decreased regional doses
blood constituents
1) < plasma protein concentration
2) pulmonary edema
3) > leucocyte count
4) hypercoagulable state (all factors > except for 11 & 13 )
5) enhanced fibrinolysis
vasodilation may increase the incidence of?
accidental epidural vein puncture
healthy parturient will tolerate up to ----ml blood loss
1,500 ml
oxytosin with a free water IV infusion may lead to?
fluid overload
high Hb level (>14) indicates low-volume state caused by?
1) preeclampsia
2) HTN
3) inappropriate diuretics
maternal BP of < 90 to 95 mm Hg during regional block should be of concern because?
it may be associated with a proportional decrease in uterine blood flow
always avoid aortocaval compression because?
70-80% of supine parturients with a T4 sympathectomy develop significant hypotension
physiologic and anatomic changes in GI system start when?
mid-first trimester
GI change
1) delayed gastric emptying
2) decreased lower esophageal sphincter tone
3) prolonged bowel transit time
4) increased gastric acid secretion
5) increased pepsin secretion
treat all pregnant pts as full stomach from?
8 weeks gestation to 6 weeks post partum
risk factors for aspiration in pregnancy
1) compromised LES function
2) higher intragastric pressure
3) anatomic displacement of stomach
4) decreased gastric emptying in labor
5) potential for emergency C/S
6) potential for diff. intubation
7) lower pH from placental GASTRIN
agents for aspiration prophylaxis
1) Ranitidine (Zantac)
2) Metoclopromide (Reglan)
3) Oral sodium citrate, 0.3M (Bicitra)
airway management in the pregnant pts
1) RSI with cricoid pressure
2) ETT intubation beyond 8-12 wks and up to 6 wks post partum
3) avoid nasal intubations
4) gastric suctioning prior to emergence
5) awake extubation
6) decrease size of ETT
ureters and renal pelvis dilate from?
week 12 - mechanical
renal system
1) ureters and renal pelvis dilation
2) RBF and GFR increase 60%
3) tubular reabsorption of water and electrolytes
4) renal threshold for glucose decreases
renal implications
1) > UTIs
2) glycosuria is common
3) > aldosterone levels = > total body Na and water
4) normal lab studies may still imply renal problems
renal problems are usually encountered with?
pre-eclampsia
proteinuria occures due to?
glomerular damage
oliguria may be a consequence of?
arteriolar damage and spasm which may lead to acute tubular necrosis
hepatic system
1) minor > in SGOT and LDH
2) blood flow unchanged
3) < plasma cholinesterase levels
4) > coagulation factors
clinical manifestations: liver
1) hypercoagulability
2) hepatic protein increase but diluted in increase plasma
3) prolongation of Succs and Miva.
neural sensitivity to local anesthetics increase or decrease?
increase: due to progestrerone
engorgement of epidural veins decreases?
epidural and subarachnoid spaces
MAC requirement?
decreases 25-40 %
progesterone production
1) corpus luterum (till 8-9 weeks)
2) placental (after 8-9 weeks)
epidural and spinal dose requirement?
decrease 20-30 %
risk for CNS toxicity?
increase during pregnancy
uterine vasculature
1) > uterine wt.
2) > uterine blood flow 700 ml/min
3) uterine vasculature is not auto-regulated
uterine blood flow (UBF)
UBF = UAP-UVP/uterine vascular resistance
factors causing decreased uterine blood flow
1) uterine contractions
2) hypertonus
3) Hypotension
4) hypertension
5) vasoconstriction (endogenous)
6) vosoconstriction (exogenous) - most sympathomimetics (alpha-adrenergic) - exception Ephedrine (beta)
Ephedrine
1) stimulates nitric oxide synthase (NOS) in uterine arterial endothelium
2) thereby counterbalancing its direct vasoconstriction
3) this does not occur in other peripheral vessels, ephedrine increases BP while sparing the uterine circulation
placenta
1) a complex organ
2) wt: 500g
3) disc shaped of 20 cm
4) 3cm in thickness
fuctions of placenta
1) produces hormones to sustain pregnancy
2) protects fetus from the maternal immune system
3) allows for active and passive transport of nutrients and metabolites
mechanisms of exchange
1) diffusion (glucose)
2) active transport (AAs)
3) bulk flow (water)
4) pinocytosis (immune globulins)
5) breaks
clinical factors affecting placental drug transfer and drug effects on the fetus
1) physiochemical properties of the drug
2) rate at which the drug crosses the placenta and amount of drug reaching the fetus
3) the duration of exposure to the drug
4) distribution characteristics in different fetal tissues
5) stage of fetal deve. at time of exposure
6) the effects of drugs used in combination
factors in placental transfer
1) lipid solubility
2) degree of ionization
3) molecular wt
4) concentration gradient
5) surface area and thickness of membrane
6) protein binding
7) maternal metabolism
fetal compartment
1) [ ] of free drug
2) time of injection vs uterine contraction
3) fetal circulation - liver
4) fetal pH
5) protein binding
6) fetal metabolism
factors affecting uptake and distribution and metabolism: 1) maternal drug concentration
maternal drug concentration
1) site of adm
2) total dose (presence of Epi)
3) maternal protein binding
4) maternal clearance and metabolism
5) maternal blood pH and pKa of drug
factors affecting uptake and distribution and metabolism: 2) pacental transfer
1) diffusion constant
2) placental factors (area, distance, metabolism)
factors affecting uptake and distribution and metabolism: 3) fetal drug concentration
1) fetal circulation
2) fetal pH
3) fetal protein binding
4) fetal metabolism (hepatic)
5) fetal drug elimination (renal)
6) tissue binding
transfer of drugs
1) inhalational agents
2) induction agents
3) opioids
4) muscle relaxants
5) anticholinergic agents
6) anticholinesterase agents
7) antihypertensive agents
8) vasopressors
9) anticoagulants