Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
292 Cards in this Set
- Front
- Back
|
cardiac changes with pregnancy[3]
|
heart enlarges
ventricular wall thicken end-diastolic volume increases |
|
|
by __ weeks, CO increases by __%
|
24-32
50% |
|
|
venous return (preload) increases because...[2]
|
increases in plasma volume
autotransfustion from uterus at birth |
|
|
pregnant women have greater baroreflex mediated changes in HR at __ than at __.
|
term
6-8 weeks postpartum |
|
|
maternal HR is __ at term
|
increased
|
|
|
a split first heart sound indicates...
|
early closure of the mitral valve
|
|
|
a 3rd heart sound can usually be heard by __ weeks?
|
20
|
|
|
__ murmurs are common.
|
benign grade 1-2 systolic
|
|
|
__ murmurs are pathologic
|
diastolic
|
|
|
maternal blood volume increases to __ at term.
|
85-100ml/kg
|
|
|
dilutional anemia and decreased blood viscosity is from..
|
more plasma (50% increase) than RBC's (20% increase)
|
|
|
normal H/H at term?
|
12/35
|
|
|
SVR decreases as much as __% by term secondary to?
|
21%
decreased resistance of uteroplacental, pulmonary, renal and cutaneous vascular beds. |
|
|
what causes pooling of the larger blood volume?
|
the venous capacitance system loses tone.
|
|
|
overall systolic BP changes..
|
very little
|
|
|
a decrease in diastolic pressure up to __mm.hg may occur resulting in a decreased __?
|
15mm
MAP |
|
|
The pregnant patient is more dependent on ___ for maintenance of blood pressure than the non-pregnant woman.
|
renin-angiotensin system
|
|
|
baseline plasma levels of __ and __ are increased during pregnancy despite the increase in blood volume.
|
renin and angiotensin
|
|
|
vascular sensitivity to angiotensin2 is ___ in the 3rd trimester whereas sensitivity to norepinephrine is __.
|
significantly reduced
unchanged |
|
|
what system provides support for MAP in the absence of sympathetic nervous system vasoconstriction?
|
renin-angiotensin system
|
|
|
the clearance of vasopressin at 36-38 weeks is ____ than before pregnancy.
Why? |
3-4 times greater
this is secondary to a 50 times increase in vasopresinase |
|
|
decreased venous return (preload) secondary to aortocaval compression results in a significant reduction in __ and __.
|
SV and CO
|
|
|
the normal physiologic responses to caval compression are...
despite this, uterine blood flow.... |
tachycardia and vasoconstriction of the LE's.
decreases |
|
|
aortocaval compression restricts flow distal to ___.
|
L3-4
this supplies the LE's and uterus. |
|
|
the upper body BP response to aortocaval conpression is?
|
nothing, the BP is unchanged
|
|
|
left uterine displacement can be achieved by __ or __.
|
OR table tile to 15 degrees left
15cm wedge under right hip and back |
|
|
LEA defeats compensatory vasoconstriction by...
|
blocking the sympathetic nerves responsible for vasoconstriction
this results in even greater hypotension to the uterus |
|
|
upper airway swelling at term is a result of ___
|
capillary engorgement
|
|
|
swelling of the false cords may cause a?
|
narrowing of the glottis
|
|
|
Term pregnancy is accompanied by an increase in o2 demand of up to __% at baseline and __% during the second stage of labor.
|
33
100 |
|
|
at term, Ve is increased by __% because of an increase in both __ and __.
|
50%
Vt(40% increase) RR(15% increase) |
|
|
at term, a normal PCO2 is..
|
32-35
|
|
|
the FRC, ER and RV are __ primarily as a result of...
|
decreased
upward pressure on the diaphragm |
|
|
what changes cause the rapid desaturation with apnea?
|
DECREASED FC
increased o2 consumption |
|
|
parturients can have __ sa02 when sleeping because of?
|
decreased
increased closing volumes |
|
|
in terms of coagulation, the parturient is said to be ___ which places the parturient at a high risk of __.
|
hyper coagulable
DVT |
|
|
normal fibrinogen is__ to __.
late pregnancy may be __ to __ __ levels are also elevated. |
200-400 normal
400-650 prego plt levels are elevated unless preeeclamptic |
|
|
during pregnancy, there is an ___ sensitivity of the nerves to LA's
|
increased
|
|
|
during pregnancy, GFR and RBF __ as a result, the __ BUN and CR __.
|
increase
decreade BUN.CR (8/0.5) |
|
|
__ levels of glycosuria and protienuria are commonly present in the absence of disease.
|
low levels
|
|
|
increased levels of __ during pregnancy result in greater gastric volume and lower pH.
|
gastrin
|
|
|
elevated levels of __ also decrease gastric motility and cause a reduction in lower esophageal sphincter tone. This is the reason for heartburn.
|
progesterone (a smooth muscle relaxant)
|
|
|
during pregnancy, levels of aspartate aminotransferrase, lactate dehydrogenase and alk. phos ______.
|
increase to the upper limits of normal
|
|
|
decreased ___ levels may result in increased free fractions of highly protien bound drugs
|
serum albumin
|
|
|
serum cholinesterase levels ___ by __% or more during the first or second trimester (recovers slightly by term)
but this does/does not change the clinical duration of action of drugs that rely on this pathway for elimination (sux, minavurium) |
decreases by 30% or more.
does not change DOA, unless 60% or more decrease in cholinesterase |
|
|
placental blood flow on the uterine side is supplied by the _____ arteries.[3]
|
maternal acurate, radial and spiral arteries
|
|
|
the __ arteries expel blod into the intervillous space
|
spiral
|
|
|
the __ sinuses receive blood from the intervillous space and returns it to general circulation
|
maternal venous sinuses
|
|
|
uterine blood flow increases to a max of ___ and account for __% of CO.
of this, approx. __ supplies nutritive flow to the myometrium and __ to the dicidua |
800ml/min 10% of CO
150ml/min to myometrium 100ml/min to dicidua |
|
|
the dicidua is the...
|
lining of the uterus
|
|
|
the fetus sends o2 poor blood to the _____.
these vessels perfuse the __ which project into the pool of maternal blood. |
2 umbilical arteries
placental villi |
|
|
the transfer of 02/C02 to the fetus is limited by..
|
the perfusion of the placenta
|
|
|
evidence of fetal embarrasement occurs if maternal systolic BP drops below ___ in awake, healthy patients during epidural anesthesia.
patients with preeclampsia can develop placental insufficiency at BP's greater than... |
100mm hg
100 |
|
|
unlike patients receiving LEA, patients receiving inhalational anesthesia seem to maintain _____ with drops in BP.
|
adequate placental blood flow despite drops in BP
|
|
|
placental transfer of free (non-protien bound) drug is dependent on..[4]
|
the magnitude of the concentration gradient
mol. weight lipid solubility drug ionization state |
|
|
drugs with molecular weights greater than 1000 daltons cross the placenta _____, less than 500 daltons cross___.
|
>1000-poorly
<500-easily |
|
|
ionized molecules are __ and __
the ____cross the placenta |
polar and water soluble
don't cross |
|
|
the chief factor in minimizing the effects of substances (drugs) that have crossed the placenta is....
|
dilution
|
|
|
before reaching the fetus, a drug is diluted in the __ blood, absorbed by the placenta, further diluting in placental blood and circulated to the fetus.
|
intervillous blood
|
|
|
approx __ of fetal CO returns directly to the placenta because of...
|
1/5th
shunt flow through the FO and DA |
|
|
serum catecholamine levels ___ in response to pain, stress and uterine activity
|
increase
|
|
|
whole body o2 demand increases an additional __% during painful contractions.
|
60%
|
|
|
each uterine contraction expels blood from the uterus into the general circulation, this increases __ and __.
|
preload and SV
|
|
|
CO in the first stage of labor increases ___ to __% during contractions and returns to prego baseline inbetween.
|
40-80%
|
|
|
increases in Ve may increase __% in respons to pain and may actually drop to ____.
|
300% increase
drop to <15 |
|
|
THE FETUS does/does not develop hypoxia or acidosis with maternal hyperventilation except when the mom is stressed.
|
does not
|
|
|
if contraindicated, give __ and __ to reduce gastric ph and volume
|
h2 blocker
metaclopramide |
|
|
unlike cimetidine, ranitadine does not...
|
inhibit the metabolism of amide local anesthetics
|
|
|
after delivery, CO may increase as much as __% above baseline because of..
|
180%
uterine autotransfusion relief of aortocaval compression |
|
|
CO remains elevated for approximately __ days as __ and __ return to normal.
|
10 days
HR and SV return to normal |
|
|
the pain of labor and delivery is mediated by _____ sympathetic nerve fibers and __ somatic nerve fibers.
|
T1-L1 sympathetic
S1-S4 somatic |
|
|
the nerves at ___ carry pain sensation from cervical dilation and are __ fibers.
|
T10-L4
C fibers |
|
|
the nerves at __ carry pain sensation from vaginal and perineal areas.
|
S1-S4
|
|
|
'Back labor" pain results from referred pain to ____ and ____.
|
dermatones and sclerotomes
|
|
|
____ are located several inches below the actual vertebral level of involvement, causing the pain to be felt over the ___ region.
|
sclerotomes
L5-S1 |
|
|
The sclerotome pathway (L5-S1) can be interuppted by a _____ or ______ with a LA level up to the __ sensory dermatome.
. |
paracervical block
lumbar sympathetic block T10 |
|
|
compression and stretching of the pelvic musculature and ligaments produces a pain that is mediated by the ______
this pain can be eliminated with a ___ |
sacral plexus
pudendal nerve block |
|
|
in a normal laboring patient, a lumbar epidural block effectively relieves the pain of ___ and __ and under some circumstances also provides effective __ analgesia.
a _ |
pain of uterine contractions and cervical dilation
sacral (do a pudendal for this) |
|
|
LEA PROBABLY prolongs ____ stage of labor but if properly conducted, has ___ effect on active labor.
|
prolongs latent
little effect on active |
|
|
complete sensory anesthesia (too dense_ eliminates _____
|
a woman's signal to push
|
|
|
the goal of LEA is to....
|
provide analgesia for labor that does not remove maternal awareness of uterine contractions and that does not cause a motor block
|
|
|
the most readily available method for assessment of the fetal well being is the --
|
FHR
|
|
|
the FHR also reveals information about fetal response to ____
|
anesthetic interventions
|
|
|
the FHR is recorded at 3cm/min.
__ is recorded concurrently on a second channel below the FHR tracing. |
uterine tone or pressure
|
|
|
given a reasonable maternal o2 saturation, fetal oxygenation is limited primarily by..
|
uteroplacental blood flow
|
|
|
anything that decreases maternal BP or uterine blood flow also decreases _____.
This results in __ and evtually __. |
uteroplacental blood flow
fetal hypoxia acidosis |
|
|
the normal FHR is.
|
120-160
higher with immature |
|
|
fetal bradycardia down to ___ is generally well tolerated if it lasts less than ____.
|
100bpm
less than 2 minutes |
|
|
feta bradycardia less than ___ is cause for consern and ____ is severe, regarless of duration.
|
<100
<80 severe |
|
|
FETAL TACHCARDIA IS __ in a full term fetus. In a few circumstances, it may be the result of hypoxia, but never when normal variability is present.
|
>160
|
|
|
most common causes of fetal tachycardia include...[5]
|
fever
fetal arrhythmia immaturity drugs (atropine, terbutaline) possible ephedrine |
|
|
fetal bradycardia is ___
caused by...[4] |
<120
hypoxia drugs arrhythmias asphyxia |
|
|
baseline variability increases with __
|
gestational age
|
|
|
beat to beat variability can be assessed only with a __ electrode.
|
scalp
|
|
|
long term variability is..
AKA>>> |
acceleration for short periods followed by a return to baseline
reactivity |
|
|
long-term variability is often associated with..
normal when the basline HR varies only by ___ on a frequent and regular basis. |
fetal movement
15bpm for 15 sec variability is considered decreased or absent when the baseline rate changes are less than this |
|
|
during fetal sleep, short-term variability should ____. but long term variability normally ___ for periods up to 40 minutes.
|
continue
decreases |
|
|
_____ is the single best non-invasive clinical indicator of fetal well being.
|
FHR variability
|
|
|
beat to beat and long term variability are seen to occur together and probably represent an ______
|
intact CNS
|
|
|
changes in beat to beat variability are ___ mediated
|
vagally
|
|
|
hypoxia causes _____ which results in decreased variability.
|
CNS depression
|
|
|
causes of decreased variability include [7]
|
hypoxia
fetal sleep acidosis anencephaly CNS depressant drugs autonomous agents defects of the fetal conduction system |
|
|
administration of opioids to the mother _____ variability for upt to 30 minutes.
|
decreases
|
|
|
maternal Magnesium may _____HR variability
|
attenuate
|
|
|
FHR variability is indicative of _____
|
fetal reserve
|
|
|
the presence of normal variability is a sign that..
|
the fetus is healthy or well compensated
|
|
|
decreased variability may be a sign that...
|
the fetus is beginning to decompensate, especially with variable or late decellerations
|
|
|
short and long term variability decrease when scalp pH is ____
|
7.2 or less
|
|
|
the sinusoidal FHR tracing is a pattern of...
associated with.. |
consistent, repeating variability superimposed on a background of a normal FHR.
anemia, butorphanol frequencyof 2-5 cycles/minute amplitutde of 5-10 bpm |
|
|
early decelerations occur ___ with uterine contractions.
they begin when ___ they end when___ |
in concert with
contractions start contractions end |
|
|
early decelerations are __ in appearance, ___ in HR change.
caused by... |
smooth
mild (<20bpm) may be from pushing too early against a less than dilated cervix or from impending delivery |
|
|
early decels are physiologic unless seen with..
|
fetal tachycardia or loss of variability
|
|
|
variable decelerations occur with ______, but not with _____
|
uterine contractions
every one |
|
|
variable decelerations may/are....[6]
|
-start early or late
-end after the contraction ends, sometimes with transient tachycardia -abrupt in occurance and recovery -FHR may pl;unge to 60 in only 1-2 sec -variable in occurence, onset, rate, depth, duration and appearance -beat to beat variability remains present during decel. |
|
|
with variable decelerations, beat to beat variability during the deceleration.
|
remains present
|
|
|
variable decelerations are severe if...
|
FHR <60 or deceleration is sustained for 60 sec or longer
|
|
|
less severe variable decelerations are still of concern if _____ is absent.
|
beat to beat variability
|
|
|
if the fetus is comprimised, the recovery phase of the variable deceleration my be ____
|
delayed
|
|
|
if variable decelerations continue to occur, the anesthetic should anticipate...
|
obstertic intervention
|
|
|
late decelerations...[5]
|
-begin 10-30 sec after onset of contraction
-smooth in onset/recover -regular in occurance -beat to beat may or may not be present -as the fetus decompensates, the recovery takes longer |
|
|
a fetus with late deleratins and absent beat to beat variability is likely to have a _______ and/or _______
|
metabolic acidosis
myocardial depression |
|
|
late decelerations are severe if FHR is_____
probably caused by.. |
<45
a problem with the placental-utero interface that is resulting in fetal hypoxia and acidosis |
|
|
______ late deceleration is a reason for concern.
|
ANY
|
|
|
even small, almost imperceivable late decelerations may represent severe fetal decompensation when they are combined with the absence of ______
|
FHR variability
|
|
|
if late decelerations are not corrected _____ must occur
|
emergent C-section
|
|
|
when presented with any FHR abnormality that may indicate hypoxia, the anesthetist must rule out _______ as the cause.
|
anesthetic intervention
most common-epidural/hypoxia treat with IVF's, ephedrine check dermatome level |
|
|
when making the decision as to whether to use an epidural block for and emergent c-section, consider....[5]
|
-is the block uniform or patchy?
-hypotension with additional LA admin? -how fast will the onset be? -chances the block will fail? -if no epidural than.GETA |
|
|
emergent c-section IV placement?
|
SEVERAL above the wrist.
|
|
|
treatment for Mag OD?
|
CACL
|
|
|
The concentration of atropine in a syringe decreases by __ over 24hrs secondary to__.
|
44%
absorption |
|
|
disadvantages to IV opioids (solely) for OB anesthesia.[5]
|
inadequate pain relief
fetal CNS depression maternal resp depression n/v decreased lower esophageal sphincter tone |
|
|
meperidine ___ the placenta ______.
|
crosses easily
causes less neonatal depression than morphine <100mg OK higest neonatal depression if given within 2-3 hrs of delivery ion-trapping to fetus, normeperidine stays, leads to a higher % of drug in fetus than in mom. |
|
|
BOTH meperidine and normeperidein can be antagonized by...
|
naloxone
|
|
|
____ of butorphanol is eqipiotent to __ of
advantages/disadvantages of butorphanol |
2mg
10mg less resp depression at higher doses better sedative than pure opioids can increase cardiac workload |
|
|
ketamine produces a ______ mediated effect.
advantages/disadvatages |
centrally and peripherally
bronchodialtor give with versed slighly increases uterine blood flow upto 1mg/kg only crosses placena easily, lipid soluble onset 1 min, DOA 5-10 min |
|
|
additional H/P info if doing regional...[9]
|
-level of dilation/effacement
-station -FHR, assess variability -membranes intact? -gestational age -gravity/parity -bleeding/back problems? -Risks/benefits -LEA is not mandatory, other methods available |
|
|
GxPxAbx????
FPAL??? |
G-# conceptions
P-# live births A-# preterm dead births FPAL-full term, premature, abortus, living |
|
|
bupivicaine cardio-toxicity is worsened in prego d/t..
|
increased progesterone levels
|
|
|
ropivicaine is the ___ of _____.
other facts... |
S-isomer of bupivicaine
t1/2 5.2 hours (bupiv-10.9) markedly less toxic 1/3 less motor block slower onset goes away quicker 1/3 less dense |
|
|
must be in ___ labor for LEA
|
active
|
|
|
active labor is...
|
3cm-pri
4cm-multi |
|
|
before performing an epidural block...
|
-check room
-new containers/vials -baseline BP -fentanyl 50-100mcg IV (limit 1mcg/kg, esp <2hrs before birth) |
|
|
epidural levels...
other facts... |
early labor-L2-L3 (less volume needed)
5cm in epidural space goal L4-T10 coverage |
|
|
stage 2 labor is...
|
delivery of fetus
|
|
|
when the patient lies down, the distance from the skin to the epidural space ____.
|
increases
this can pull out the epidural if taped in the sitting position tape after side-lying with legs straight side hole/closed end results in more satisfactory blocks |
|
|
test dose for epidurals?
|
lido 30mg/epi 15 mcg
or bupiv 10mg or chlorporcain 60mg observe for blood/CSF when aspirating!!! |
|
|
the spread of analgesia when an epidural catheter is placed is primarily determined by..
the extent of anesthesia with a spinal is determined by.. |
epidural-the volume of LA solution injected
spinal-the dose, baricity and position |
|
|
normal, healthy late teens.20's need ___ml per dermatome level of spread.
|
1ml
|
|
|
volume for lumbar epidural at L2...
|
average 16cc for T6-S4
|
|
|
average epidural dose...
infusions... |
6-12 cc of 0.1%-0.2% ropivicaine
or 0.125-0.25% bupivicaine..incrementally (5cc) infusion: 0.0625-0.2 )10-15ml/hr along with 1-2 mcg/ml fentanyl |
|
|
the addition of fentanyl to the LA.....[3]
|
speeds the onset, increases density, and prolongs durations
|
|
|
the ideal block provides...[3]
|
analgesia for labor pain
densde analgesia of the perineum for delivery little motor block |
|
|
the most common method to prevent maternal hypotension after LEA is...
|
replacement of fluid volume (not proven)
|
|
|
a small reduction in plasma colloid osmotic pressure results in..
|
strong inhibition of ADH release
|
|
|
vasopressin release (ADH) in response to loss of intravacular volume requires a ___ stimulus
|
a fairly strong stimulus
|
|
|
the volume of crystalloid IV preload commonly employed to prevent maternal hypotension may actually inhibit the....
|
body's efforts to support BP by delaying or reducing the magnitude of vasopressin response
|
|
|
regulation of MAP in healthy pregos undergoing LEA is most strongly influenced by__.
|
SVR
|
|
|
effective prevention of maternal hypotension must include interventions to maintain maternal ___ without increasing uterine arterial resistance.
|
SVR
|
|
|
_____ is probably the most frequent complication in obstetric anesthesia.
|
hypotension
|
|
|
intervillous blood flow is dependent on..[1]
|
maternal MAP
|
|
|
fetal oxygenation is dependent on..[2]
|
maternal MAP and intervillous blood flow
|
|
|
in healty pregos, the critical duration of hypotension is probably greater than ____.
the critical magnitude of hypotension is ____. |
2 minutes
SBP<100 |
|
|
______ is a non-selective, non-catecholamine sympathomimetic drug.
|
ephedrine
|
|
|
ephedrine dose, duration, S/A's, facts
|
5-25mg IV to tx BP
5-10 mg IV lasts 5 min tachycardia can occur with repeated small doses and decreased clinical effects T1/2 isa 3 hrs (liver) 40% renal unchanes direct beta, indirect alpha AFFECT uterine arterial flow the least of all vasopressors 250x less potent than epi crosses placenta (70:100) ratio |
|
|
phenylephrine use?
|
safe, use if ephedrine causes too much tachycardia
|
|
|
aspiration pneumonitis prophylaxis? [3]
|
BICITRA 30CC PO
10-20mg Reglan (slow IVP) H2 (pepcid/ranitadine) IV or PO |
|
|
avg EBL's?
|
reg-500
c-section-700 |
|
|
factors effecting blood loss during c-section include...[8]
|
-surgical time
-surgical technique -BP -fetal lie -fetal size -placental implantation -materanl coagulation status -ability of uterus to contract after placenta has been delivered. |
|
|
risk factors for excessive bleeding with c-section? [6]
|
-GA
-amnioitis -preeclampsia -protracted phase of labor -second state arrest -hispanic ethnicity |
|
|
__ and __ make maneuvering of the laryngoscope difficult.
|
breast enlargement
cephalad movement of the thorax |
|
|
appropriate induction agents./doses
|
THIOPENTAL 3-5 mg/kg
ketamine 1mg/kg iv etomidate 0.3mg/kg IV propofol |
|
|
ketamine is especialy useful in patients who have ...
|
reactive airway disease or hypotension
|
|
|
___ is the preferred muscle relaxant for GETA with parturient.
|
sux
|
|
|
sux is metabolized by...
|
pseudocholinesterase
|
|
|
PCHE activity is normally ____ in healthy pregos at term.
|
decreased 30%, up to 60% with preeclampsia
LEADS to a prolonged DOA |
|
|
sux's duration will be prolinged in patient's receiving ____
|
magnesium
|
|
|
metaclopramide will proling the DOA od agents being metabolized through./..
|
ester hydrolysis
|
|
|
once apnea occurs, maternal o2 saturation drops_____ times as fast as in a non-prego.
|
3 times as fast
|
|
|
essential monitors during intubation are..
|
pox
capnograoph |
|
|
____MAC of an inhalational agent can be used safely during C-section
this level decreases uterine contractility by... |
2/3 MAC
.75 iso 1.7 sevo 4.8 des 25% therefore, stop the inhalational agent ASAP after the delivery |
|
|
if fetal distress is present or maternal sao2 is less than 97%...
|
100% o2
|
|
|
potential for increased free-radical activity in neonates who's mom's had....
but.... |
high Fi02
infants born to these mom's had slightly better outcomes |
|
|
a ___ is the classic technique for muscle relaxation during c-section.
there is a risk of.. |
sux gtt
prolongs phase 2 block |
|
|
if tubal ligation is performed at the same time as c-section, what paraylytic can be used?
|
non-depolarizer
|
|
|
interval from incision to delivery is best...
|
<3 minutes, if greater the risk of acidosis increases
|
|
|
anesthetic options dramatically changes when...
|
the cord is clamped
|
|
|
after the cord is clamped, ____ and ____ work well and do not affect uterine tone.
|
opioids and N20
|
|
|
oxytocin is a naturally occuring hormone synthisized in the ____ and __ of the ___.
|
supraoptic and paraventricular regions of the hypothalamus
|
|
|
in the mature uterus, oxytocin causes....
|
an increase in the frequency and strength of contractions
|
|
|
endogenous oxytocin release occurs with stimulation of the...
|
cervix, vagina, breast
|
|
|
t1/2 oxytocin?
|
4-17 minutes
|
|
|
commercially available preps of oxytocin contain a _____ that causes sysolic and esp. diastolic hypotension, flushing, and tachycardia when infused at high doses.
|
preservatives
|
|
|
in general, the OB is likely to desire the administration of ______ units of oxytocin over the first hr post-partum
|
30-40 units
|
|
|
if oxytocin does not work...
these cause a... |
ergot alkyloid. (ergonate)
IM 0.2mg increase in BP, CVP ans PAWP |
|
|
ergot alkyloids potentiate...
can cause.. |
ephedrine and esp. alpha agonists
severe hypertension, CVA, RETINAL DETATCHMENT when given together |
|
|
if ergot alkyloids dont work....
|
protaglandid F2 250mcg IM or intrauterine
causes strong, painful contractions n/v, diarheaa |
|
|
suctioning the stomach with an orogastric tube while the patient's asleep decreases the incidence of ___ after awake extubation
|
vomiting
|
|
|
epidural block during c-section...
|
bupiv-0.5% (30 min onset)
lido 2% (10 min onset) nahco3 1meq.l speeds onset (5min or less) also makes more dense, speed of onset may make hypotension a problem no advantage with bupivicaine, only lido 2-chlorprocaine-fast onset, high incidence of backache, ester hydrolysis |
|
|
disadvantages of throught the needle combined technique.
|
higher incidence of hypotension
in intravascular, more severe and faster onset |
|
|
the duration and density of blocks can be increased by the addition of >>>>
|
epi
|
|
|
using an opioid with LA for epi/spinal decreases noxious.pain during exteriorization of the uterus.
dose? |
50-100 mcg
|
|
|
Spinal/Subarachnoid doses.
|
tetracaine 10-15mg o-15 d-90
bupivicaine 10-15mg 90 lido 75-100 5(50-60) the addition of fentanyl prolongs duration, increases density without the prolongation of motor block and urinary retention seen with epi |
|
|
when opioids are used with regoinal anesthesia....
doses |
-decreased dose
-less motor blockade -act on substantial gelatinosa in cord fentanyl 50-100 mcg epidural 10-25 mcg spinal DOA 3-4dhrs, less cephlad migration than MS *most women have undetectable serum levels after receiving 100 mcg fentanyl infusion-up to 2.5mcg/ml wont affect neonatal scores NO FENTANYL WITH 2-CHLORPROCAINE (antagonized) sufenta-more potent, shorter DOA |
|
|
most common S/A Morphine epidural?
|
puritis
none in obese parturients decreases Ve too much use Pulse ox post partum!! |
|
|
S/A's of regional are more common with spinals or epidurals?
|
spinals
|
|
|
IV doses of __ and ___ are effective at reducing or eliminatinf the undesirable S/A's without antagonizing the analgesia and are more effective than antihisatmines against purtits.
|
naloxone
nalbuphine |
|
|
there is an increased incidence of puritis with the use of _____.
|
epi in LA doses
|
|
|
N/V is closely related to ...
|
hypotension
|
|
|
a total sympathetic block results in unoppesed vagal stimulation which predisposes the patient to >>>
|
N/V
|
|
|
THE administration of an_______ right before the SA/Epidural prevents nausea by limiting unopposed vagal stimulation
|
antimuscarinic (atropine.glycopyrolate)
|
|
|
________ have been shown to significantly reduce the incidence of post c-section N/V resulting from regional iopioids.
|
scopolamine patches
|
|
|
Scopalamine patch onset, DOA, S/A's
|
onset 2-4 hours
48Hr DOA dry mouth/dizziness |
|
|
CSF production?
|
150 in dura, 500ml/day
|
|
|
__ can mimic PDPH in the initial stages (HA, photophobia)
|
meningitis
|
|
|
PDPH severity of sx's are related to __ and __.
|
volume and rate of CSF leak
|
|
|
increase PDPH incdence with __ vs ___ needles.
|
beveled (qincke)
pencil (sprotte) |
|
|
Hallmark appearance of PDPH is its _____ nature.
HA features... onset? |
postural
relieved by lying down, returns when standing frontooccipital occ. neck/shoulder stiffness severe photophobia double vision onset 1-2 days |
|
|
PDPH tx
|
supine
hydration caffiene 300mg serotonin receptor antagosnists definitive tx-blood patch |
|
|
blood patch tech..
|
the epidural blodd patch plugs the dural rent with a fibrin clot and the Increased pressure.
same interspace or 1 below 20ml blood draw inject 15-20 supine for 1 hr take it easy |
|
|
signs of LA toxicity...
tx... |
tiniitis (first)
other changes in hearing, confusion. inability to speak, metallic taste, cirumoral numbness stop infusion! barbiturates/benzos to stop sz control airway, ETT, o2 |
|
|
accidental SA injection leads to...
|
dyspnea with hypotension
tx sx's |
|
|
accidental subdural injection (between dura/arachnoid)
|
more cephlad spread (sudden after 10-25 min)
hypotension is ussually primary problem, tx with ephedrine |
|
|
EKG changes during c-cestion are/are not ussually myocardial ischemia.
|
not
|
|
|
CPR?
|
left uterine displacement
c-section in 5 min if no go. |
|
|
maternal mortality rate?
|
7.5:100,000
|
|
|
most common cause of maternal death is...
|
hemmhorage followed by
embolism preeclampsia infection cardiomyopathy |
|
|
______ is a leading cause of perinatal M&M.
|
premature delivery
|
|
|
____ is implicated in more than 50% of all perinatal deaths.
|
premature delivery
|
|
|
___% of all live births in US are premature.
|
9%
|
|
|
premature labor is defined as...
|
regular uterine contractions that occure between 20-37 weeks that result in dilation and effacement of the cervix.
|
|
|
risk factors for premature labor...[8]
|
race
weight drug use stress parity multiples extremes of maternal age complications |
|
|
traditionally ____ was used to stop labor. It depresses myometrial contractility and suppresses the release of oxytocin from the post. pituitary.
S/A's [5] |
ethyl alcohol
increased gastric volume depression of airway reflexes vomiting lactic acidosis fluid/elec imbalances |
|
|
Magnesium Sulfate causes....
|
relaxation of vascular, bronchial and uterine smooth muscle by altering calcium transport and availability.
motor end-plate sensitivity and muscle membrane excitability are also depressed |
|
|
Nl mag in prego..
tocolytic at.... resp depress at... apnea at... arrest at.... |
1.8-3.0
4-8 tocolytic >12 resp depress >18 apnea >25 arrest |
|
|
mag S/A's
|
skeletal muscle weakness
CNS depression vascular dilation decreased BP during epidural antagonizes vasoconstrictive effects of ephedrine/NEo cutaneous flushing HA/dizziness weakness depressed DTR's EKG changes resp depression |
|
|
All ____ are potentialted by Mag.
|
NMB's
|
|
|
Mag is partially antagonized by..
|
CaCL
|
|
|
Mag tx's preeclampsia by...[3]
|
relaxing smooth muscle
decreasing SVR decreasing BP |
|
|
progesterone cause histologic changees in...
|
myometrial cells that limit the spread of contractile impulses
|
|
|
beta agonists cause...
|
smooth muscle relaxation, including the uterus and increases progesterone production
|
|
|
Maternal S/A's of beta-1 stimulation.
|
-cerebral vasospasm
-CP, tightness -glucose intolerance -hypokalemia -illeus -myocardial ischemia -N/V -palpitations -restlessness -tremor -ventricular arrythmias |
|
|
maternal beta-2 S/A's [4]
|
-vasodilation
-bronchodilation -increased secretions -various metabolic effects |
|
|
Both __ and __ can antagonize HPV through beta-2 mediated vasodilation.
|
ritodrine and terbutaline
this can drastically decrease maternal o2 concentrations |
|
|
BETA stimulation increases BS and insulin levels which can cause...
|
hypokalemia
|
|
|
beta agonists increase risk for ___ in parturients preloaded for regional anesthesia.
|
PULMONARY EDEMA
|
|
|
risk factors associated with pulmonary edema during beta agonist tocolysis...[5]
|
anemia
fluid overload magnesium mutilples prolonged maternal tachycardia |
|
|
beta agonists effect on neonate/fetus...
|
tachycardia is common
hypoglycemia in neonates |
|
|
ritodrine (Yutopar) is a selective beta2 agonist. The average increase in maternal HR is....
facts... |
40bpm
increased SBP,decreased DBP risk for pulmonary edema no more than 2L fluid over 24hrs |
|
|
terbutaline (Brethine, Bricanyl) is a synthetic, relatively beta2 specific, non-catecholamine, sympathomimetic amine
less beta specific than ritrodrine facts....[4] |
-more chance for arrhythmia
-tachycardias -longer 1/2 life -risk for pulm edema |
|
|
when tocolysis fails, preterm deliveries by c-section using epidurals show a higher 1/5 minute APGAR score than with GA.
|
if rito/terb on board, than no volume load...GETA
|
|
|
No dose of ____ with mag.
|
non-depolarizing defasciculating dose
|
|
|
No _____ if on a beta-agonist
|
vagolytic
|
|
|
Labetolol is a selective alpha-1 and non-selective beta agonist that decreases maternal BP while maintaing...
|
placental blood flow
|
|
|
No ____ with beta agonist.
|
Halothane, it sensitises the myocardium to catecholamines
|
|
|
____ reduces MAC
|
magnesium
light anesthesia is bad, it increases the maternal catecholamine output and decreased uterine blood flow. |
|
|
the prego has a ____higher risk for PE.
|
5 TIMES
|
|
|
PE is most likely in the __ period.
associated with...[5] |
postpartum
prolonged inactivity C-section obesity increased age increased parity |
|
|
s/s PE...[7]
|
pleruitic CP
dyspnea hyperventilation hypocapnea hemoptysis neck vein distension coughing |
|
|
while in the OR/delivery, the chances of a PE are..
|
less likely than an air aor amniotic embolus
|
|
|
a venous air embolus can occur during labor, spontaneous vaginal delivery and operative delivery and is associated with...
|
placenta previa
|
|
|
amniotic fluid embolus is rare and ussually fatal and is associated with
|
placental abruption
|
|
|
most venous air embolisms are detected when?
|
between delivery and uterine repair
|
|
|
s/s venous air embolism [5]
|
millwhell murmur over precordium
CP dyspnea decreased ETCO2 increased CVP |
|
|
s/s amniotic fliud embolism
|
tachypnea
pulmonary edema chill shivering anxiety cough dyspnea cyanosis decresede sao2 CV collapse |
|
|
there is a _____ incidence of thrombolic emboli with regional anesthesia.
|
decreased
|
|
|
if air/amniotic embolus suspected, tx...[3]
|
flood with NS
return uterus to abd stimulate contractions |
|
|
EBL with c-section/hyster
|
1500
|
|
|
hypotension may not occur until ___% of blood volume has been lost
|
30%
|
|
|
placenta previa
|
1%
risk of sudden large blod loss needs c-section regional only if SKILLED |
|
|
placenta abruption
|
MAJOR BLEEDING like trauma
DIC 50% (embolus) increased risk with preeclamp 22% GETA fast up tp 5L blood concealed in abd1 |
|
|
atonic uterus
|
bleeding
no inhalants oxytocin/ergots/protaglandin NTGIV/sl spray get fragments out accounts for 80% of all bleeding |
|
|
uterine rupture
|
HEAVY bleeding like trauma
800ml/min VBAC cocaine sudden sever pain, tearing in multipart suring heavy labor fhr tracing!!!!! |
|
|
the clinical finding most commonly associated with uterine rupture is
|
abnorma FHR tracing
|
|
|
placental acrreta
placental increta placenta percreta |
placental acrreta-on myometrium
placental increta-in myometrium placenta percreta-through myometrium all have large blood loss |
|
|
DIC associated with..[3]
tx.. |
retention of dead fetus
placental abruption aminotic embolus volume, support, eliminate cause before replacing factors uncontrolled bleeding from consumption of factors decreased fibronogen |
|
|
multiples [4]
|
risk for uterine atony
NO oxytocin til last baby is out, then lots! aortocaval syndrome epidural |
|
|
preeclampsia
|
vasospastic dz of pregnancy
2.6-6% abnormal thromboxane (constrictor, aggregator) to prostaglandin (smooth muscle relaxant) ratio. increased SVR!!! 1-2+ protienuria, edema after 20th week, HTH (2of3=diagnosis) 140/90 or 30/15 above sever if 3-4+ protienuria 160/110, u/o <20ml/hr CNS(blurred, mentation) pulm edema epiugastric pain BP is key indicator |
|
|
with preeclampsia the chief cause of maternal mortality is
|
cerebral hemmorhage caused by HTN
others-pulm edema, hepaticv rupture, DIC, cerebral edema RF |
|
|
with preeclampsia there is an increased sensitivity to
|
catecholamines
ephedrine vasopressin, AT2 |
|
|
with preeclampsia, uteroplacental insufficiency can reslt from...[3]
|
low intravascular volume
vascular intimal deterioration increased vascular resistance placental perf can decrease by up to 70% |
|
|
preeclampsia tx..
|
mg (decreases ecclampsia byt 58%, deaths by 45%)
avoid decreases in uterine blood flow maximize organ perfusion regional if possible |
|
|
HELLP
|
1-% OF PREECLAMTICS
hemolysis elevated liver enzymes low platelet count |
|
|
pay attention to ____ when starting a regional with preeclampsia
|
coags
|
|
|
bleeding time is ____ normal
|
5x
|
|
|
use ephedrine/vasopressors with care in preeclamptic patients because...
|
the can have exagertted responses
|
|
|
with preeclamtic regional, ____ is DOC
|
bupivicaine, slower onset
|
|
|
most common cause for GETA with preeclampsis?
|
coagulopathy
deteriorating condition |
|
|
preeclamptics can have an exageratted response to laryngoscopy.
|
56mm average WITH antihypertensives
labetolol alfentanil 10 mcg/kg 1 min before |
|
|
labetolol
|
up to 1mg/kg
shorter 1\2 life in pregos (1.7hrs) |
|
|
hydralazine
|
may improve UPBF
onset 10-20 min |
|
|
NTG [3]
|
low placental transfer
make sure the patient has adequate intravascular volume may increase ICP (esp NTP) |
|
|
non-depolarizers are markedly potentiated with preeclampsia and therpeutic Mag levels
give... |
1/2 ED95
|
