Olson, Ob Iv (2Nd Half)

Front 1

What neuro problems r/t pregnancy or L&D occur in the lithotomy position?

Back 1

Injury to Femoral nerve (L2-L4) - numbness of thigh, calf, paralysis of quad
Injury to sciatic nerve
Injury to Obturator nerve (stretch injury)
Common Peroneal nerve injury - compression of lateral knee, foot drop
Saphenous nerve Injury - numbness over medial foot

Front 2

What is Cauda equina syndrome associated with?

Back 2

Associated with use of bisulfite additive in Nesacaine in past.
More recently associated with use of small micro catheters left in place for continuous SAB

Front 3

What are the symptoms of Cauda Equina Syndrome?

Back 3

numbness and varying degrees of LE paralysis and sphincter dysfunction
Usually permanent

Front 4

What is a prolonged block usually associated with?

Back 4

High concentrations of locals (last 10-48hrs)
Bladder dysfunction (overstretch) may result

Front 5

What is nerve root trauma r/t with SAB/Epidurals?

Back 5

Direct trauma by needle or catheter (rare)
Intraneural injection - neuritis followed by paresthesia for several months occurs.

Front 6

What are the symptoms of transient neurologic syndrome and what is it associated with?

Back 6

Low back pain radiating to hips and legs.
Seen after use of 5% hyperbaric Lidocaine (spinal Lido)

Front 7

What are the symptoms of an epidural hematoma and what causes one?

Back 7

Progressive paralysis of LEs, may have low back pain.
Caused from trauma to epidural vessels when abnormal coags
Mus DX and Tx w/in 6hrs or permanent paralysis may occur.

Front 8

What are the symptoms of an epidural abscess?

Back 8

Severe back pain, local tenderness, fever, and increased WBCs

Front 9

What is adhesive arachnoiditis and what are the symptoms?

Back 9

A clinical irritation of subarachnoid space from contamination of spinal needles or solutions.
Symptoms are HA, nuchal rigidity, N/V, fever, Kernig's sign

Front 10

How do you problem solve an asymetrical block?

Back 10

Have patient turn change positions
Check for catheter migration and pull catheter back if needed

Front 11

What should you do if you have a patchy block?

Back 11

Check position
Top up with 4-6 ml of 0.25% bupivacaine
Try increasing rate/concentration of infusion
Give an opioid (epidural)
Check for bladder distension
Redue if in doubt that epidural is in properly.

Front 12

What is the technique for a combined spinal epidural (CSE)?

Back 12

Identify epidural space in normal fashion.
Pass 24-27G pencil point spinal needle through epidural needle until CSF aspirated
(spinal needle will extend ~1.5cm past epidural needle)
Inject meds into spinal needle
Withdraw spinal needle and threat epidural catheter
Test and dose epidural when discomfort returns (usually 1.25-2hrs)

Front 13

What meds are used for combined spinal epidural?

Back 13

10-25mcg Fentanyl or
2.5-10mcg Sufentanil in 1-2ml PFNS
1ml of 0.25% bupivacaine (isobaric, PF) with narcotic

Front 14

What are the advantages of combined spinal epidural?

Back 14

Rapid onset of analgesia (2-5min)
Less opioid and local required
Less motor block
Increases epidural success
Not as likely to slow labor as epidural
Greater patient satisfaction

Front 15

What are the disadvantages of combined spinal epidural?

Back 15

Spinal portion ineffective 10% of time
Increased expense
Risk of fetal bradycardia after intrathecal narcotic
Increased incidence of itching with spinal opioid
Slight increased risk of PDPH

Front 16

What is Caudal anesthesia?

Back 16

Lowermost part of epidural space. May place epidural or one shot technique
Not popular - requires large amount of local for T10

Front 17

What is a Paracervical block?

Back 17

Placed by obstetrician, place local into paracervical tissue.
Usually during first stage of labor
No block of perineal pain
Fetal bradycardia may be seen after block

Front 18

What is a Pudendal Block?

Back 18

Placed by Obstetrician 10ml of local placed transvaginally to both sides just before delivery.
Local uptake similar to epidural.

Front 19

How do you define hypotension with regional anesthesia and how do you treat it?

Back 19

Decrease in SBP to <100mmHg
Decrease in SBP of >30mmHg from baseline
Treat it with 1-2L crystalloid before block.
LUD
Ephedrine 5-15mg or low dose neosynephrine

Front 20

How do you treat a total spinal?

Back 20

Maintain airway - intubate ASAP to prevent aspiration
LUD
Fluids and ephedrine
FHR monitoring to determine need for emergent section
May need thiopental or diazepam for seizures

Front 21

What are the absolute contraindications for regional anesthesia?

Back 21

Patient refusal
Increase ICP
Infection at insertion site
Sepsis
Hypovolemic shock
Coagulopathies

Front 22

What are relative contraindications for regional anesthesia?

Back 22

Pre-existing neuro disease of spinal cord or peripheral nerves
Systemic infection

Front 23

True or False:
Chorioamnionitis is an absolute contraindication to spinal/epidural anesthesia.

Back 23

False, it is a relative contraindication.

Chorioamnionitis occurs when PROM allows bacteria to enter amniotic cavity.
Symptoms of temp <38, tachycardia, uterine tenderness, foul smelling amniotic fluid, increased WBC

Front 24

Intraspinal and epidural opioids reach intraspinal receptors by penetrating the ______ of ______.

Back 24

Superficial Laminae of Dorsal Horn.

Front 25

True or False:

Low pKa and High lipid solubility is associated with Rapid onset of action.

Back 25

True.

Front 26

What are the advantages of adding opioids to epidurals?

Back 26

More effective for stage 1 & 2 of labor
Allows reduction of local and nonepidural opioids.
Possible synergistic effects

Front 27

How do you dose an epidural with opioids for a C-Section?

Back 27

Fentanyl 100mcg
Morphine 3-5mg can provide post-op analgesia for 12-24hrs.
Not as effective if used after Nesacaine (2-Chlorprocaine)

Front 28

What intraspinal opioids can be used for C-section?

Back 28

Fentanyl 10-25mg
Morphine 0.1-0.3mg (provides pain relief for 18-27hrs)

Front 29

What are the complications for intraspinal/epidural opioids?

Back 29

Pruritus (most common)
N/V
Urinary retention
Somnlence
Neonatal effect minimal w/low doses
Delayed respiratory depression

Front 30

How can you treat pruritus r/t intraspinal/epidural opioids?

Back 30

Naltrexone 12.5-25mg PO
Naloxone 0.1-0.2mg IV
Benadryl 25-50mg PO or IV
Nubain 5-10mg IV

Front 31

True or False:
Delayed respiratory depression is more common with epidural morphine than intrathecal morphine.

Back 31

False, more common with intrathecal.

Front 32

When does Delayed respiratory depression occur with morphine?

Back 32

May occur 6hrs or more after administration.
Greatest risk between 4-8hrs
Young at less risk than old
Those with coexisting pulm disease are at increased risk