Easy Points : Physio OB - Obstetrics Anesthesia

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orcl777
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Easy Points : Physio OB - Obstetrics Anesthesia
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2013-12-12 10:38:07
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Obstetrics Anesthesia
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Obstetrics Anesthesia
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  1. what are the types of anesthesia
    • 1. Local - normal deliveries
    • 2. Regional
    •     a. Pudental Block
    •     b. Spinal Block
    •     c. Combined spinal and Pudental 
    •  3. General 
    •     a. Intravenous
    •     b. Inhalation
    •     c. tracheal intubation
  2. Accdg to ACOG and ASA when do we start giving anesthesia?
    as soon as the patient ask for pain relief
  3. What are the maternal risk factors that would prompt anesthesia consult?
    • 1. marked obesity
    • 2. severe edema or anatomic abnormalities of face, neck and spine
    • 3. abnormal dentition , small mandible, difficulty opening the  mouth
    • 4. extremely short starture, short neck or arthritis of the neck
    • 5. Goiter
    • 6. serious maternal medical problem
    • 7. bleeding disorders
    • 8. previous history of anesthetic complications
    • 9. obstetric complications likely to lead to operative delivery ex placenta previa
  4. What is the role of the obstetrician in giving obstetric anesthesia?
    Should be proficient in local and pudendal analgesia ( vaginal delivery, episiotomy, outlet forcep extraction - pudendal block/local infiltration, also paracervical block)
  5. who should do general anesthesia?
    those with special training
  6. What are the principles of pain relief?
    • 1. Labor pain is interpreted differently by individual patient
    • 2. stimuli are modified by emotional, motivation , cognitive, social and cultural circumstances
    • 3. Limited ability of woman and her caregivers to anticipate her pain experience prior to labor
  7. non-pharmacologic method of pain relief
    Lamaze
  8. pain can be lessened by relaxed breathing and psychological support of labor partner
    Lamaze
  9. Meperidine (demerol) dosage
    50-100 mg
  10. dosage and route of administration of Promethazine
    25 mg IM every 2-4 hours
  11. dosage and route of administration of Meperidine for rapid effect
    25-50 mg IV every 1-2 hours
  12. what is the peak analgesia effect of IM route of administration
    30-45 min
  13. what is the peak analgesia effect of IV route of administration
    immediate
  14. what is the importance of knowing the peak analgesic effect of IV ?
    • readily crosses the placenta
    • half-life in newborn >/= 13 hours
    • depressant effect on  fetus
  15. synthetic narcotic analgesia
    Butorphanol (Stadol)
  16. dosage of Butorphanol (stadol)
    1-2 mg
  17. Give side effects of Butorphanol (stadol)
    • Somnolence
    • Dizziness
    • Dysphoria
  18. less neonatal respiratory depression than meperidine
    Butorphanol (stadol)
  19. anatagonize narcotic effect of meperidine
    Butorphanol (stadol)
  20. associated with sinosoidal fatal heart pattern
    Butorphanol (stadol)
  21. main disadvantage is short duration of action and requires frequent dosing
    Fentanyl
  22. Fentanyl dosage and route of administration
    50-100 mcg IV every 1 hour
  23. provide better initial analgesia than fentanyl
    butorphanol
  24. In US, available in patches for continuous pain relief for cancer patients
    Fentanyl
  25. most common opioid used worldwide
    Meperidine
  26. provides superior pain relief
    Epidural anesthesia
  27. risk of IV and IM sedation
    • aspiration 
    • inadequate ventilation
    • over dosage
    • newborn respiratory depression
  28. reverses respiratory depression
    naloxone
  29. acts by displacing narcotic from specific receptors in CNS
    naloxone
  30. precipitate withdrawal symptoms in narcotic dependent
    naloxone
  31. contraindicated in newborn of narcotic mother
    naloxone
  32. mixture of N2O: O(50:50)
    Nitrous Oxide
  33. intermittent inhalation, pain not eliminated but should provide some relief
    Nitrous Oxide
  34. used as PCA ( Pain controlled Anesthesia)
    Nitrous Oxide
  35. Pathway of pain during labor
    Uterus-> visceral sensory fibers -> frankenhauser ganglion -> pelvic plexus -> middle and superior internal iliac plexus -> lumbar and lower thoracic sympathetic chains -> spinal cord T10, T12, L1 nerves
  36. what are the spinal nerves that are blocked during obstetric anesthesia
    T10, T12, L1 nerves
  37. spared with spinal block
    motor pathway T7 and T8 ( for uterine contraction) so patient can be pain-free but still have uterine contraction.
  38. pain from vaginal delivery is transmitted to what nerve?
    pudendal nerve
  39. provide sensory innervation to perineum, anus, vulva and clitoris
    pudendal nerve
  40. passes beneath sacrospinous ligament at its attachment to the ischial spine
    pudendal nerve
  41. sensory fibers from ventral braches of S2-S4 nerves
    pudendal nerve
  42. Rapid onset, local/pudental block epidural for CS
    2-chloroprocaine
  43. slow, low spinal block, spinal for CS
    tetracaine
  44. Amino-esters
    • 2-chloroprocaine
    • Tetracaine
  45. Amino-amides
    • Lidocaine
    • Bupivacaine 
    • Ropivacaine
  46. rapid, local/pudendal block, epidural/spinal for CS
    Lidocaine
  47. slow, epidural spinal for CS/Labor, spinal for CS
    Bupivacaine
  48. slow, epidural for CS/labor
    Ropivacaine
  49. metabolize in the liver and patient with severe liver problem should not be given
    Amino-amides (lidocaine, bupicaine, ropivacaine)
  50. spinal block usual duration
    1-2 hours
  51. used to prolong action of the anesthetic
    dilute epinephrine
  52. sytemic toxicity from local anesthetics typically manifests in
    CNS and cardiovascular systems
  53. which manifest earlier CNS vs cardiovascular toxicities ?
    CNS
  54. when does stimulant toxicities manifest?
    early
  55. when does depressants toxicities manifest?
    late
  56. Manifestations that will suggests possible toxicities
    • lightheartedness
    • dizziness
    • tinnitus 
    • numbness of tongue and mouth 
    • slurred speech
    • muscle fasciculations
    • loss of consciousness
  57. abolishes peripheral manifestations of convulsions and allows intubation
    succinylcholine
  58. act centrally to inhibit convulsions
    • Thiopental
    • Diazepam
  59. controls convulsions
    Magnesium Sulfate
  60. physiology of CNS toxicity
    convulsions -> maternal hypoxia and lactic acidosis -> abnormal fetal heart rate pattern (late deceleration and fetal bradycardia)
  61. induced by higher drug levels except bupivacaine
    cardiovascular toxicity
  62. associated with both neurotoxicity and cardiotoxity at identical serum levels
    bupicaine
  63. characterized first by stimulation followed by depression
    cardiovascular toxicity
  64. symptoms are hypertension and tachycardia followed by hypotension and cardiac arrythmia impaired uteroplacental perfusion and fetal distress
    cardiovascular toxicity
  65. Management of hypotension with cardiovascular toxicity
    • Turn woman to either side to avoid aortocaval compression
    • Hydration
    • IV administration of ephedrine
    • emergency CS if maternal vital signs have not restored in 5 min of cardiac arrest
  66. used of spontaneous vaginal delivery, outlet forceps and removal of some small cyst down the vagina
    pudendal block
  67. gauge needle size used in pudendal block
    15 cm, 22-gauge
  68. fill in the blanks : Pudendal block administration : 
    needle pushed unto the mucosa beneath the tip of the ________, infusion of __________, needle then advanced to the ____________  and infiltrated with ___________. Needle is advance further beyond the __________ and through the mucosa and the rest of the _____________ is infiltrated. Done bilaterally
    ischial spine, 1 ml lidocaine, sacrospinous ligament, 3 ml, sacrospinous, 10 ml lidocaine.

    I just  qualified myself as Physio-OB examiner. LOL!
  69. pain relief during 1st stage of labor, additional analgesia required at delivery
    paracervical block
  70. two techniques for pudendal block
    intravaginal and extravaginal
  71. what is the preferred technique in pudendal block?
    intravaginal
  72. where does the pudendal nerve passes ?
    ischial spine
  73. lidocaine or chloroprocaine is injected into the cervix at 3 and 9 o'clock
    paracervical block
  74. bupivacaine is contraindicated because of risk of cardiotoxicity
    paracervical block
  75. modified technique of paracervical block
    4 and 8 o'clock position  to stay away from uterine vessels ( make sure to aspirate before injecting to make sure its not hitting the vessels)
  76. used for patients with severe cardiovascular problems and advanced age during D&C procedure
    paracervical block
  77. complications of paracervical block
    fetal bradycardia ( develops within 10 min, transient 30 min)
  78. most common regional block used in cesarian section
    Spinal (subarachnoid block)
  79. advantages of spinal block
    • short procedure time
    • rapid onset of lock
    • high success rate
  80. where is spinal block introduced for injection?
    L2-L3
  81. The tip of the spinal needle is introduced into the subarachnoid space
    spinal block
  82. use for  Vaginal delivery, the level of the analgesia extend to the
    T10 dermatome—almost at the level of the umbilicus.
    low spinal block
  83. Provides excellent relief from the pain of uterine contractions.
    low spinal block
  84. Agents that can be used in low spinal block
    • Lidocaine
    • Bupivacaine
    • Both only administered with a fully dilated cervix
  85. Preanalgesic intravenous hydration with 1 L
    solution will prevent or minimize hypotension in many cases.
    low spinal block
  86. Sensory blockade extending to the T4 dermatome
    (higher than the umbilicus)
    high spinal block
  87. high spinal block agents
    Hyperbaric bupivacaine/lidocane used
  88. Additional fentanyl increases the rapidity of
    onset and decreases shivering
    high spinal block
  89. Additional 0.2 mg of morphine improves pain
    control
    high spinal block
  90. saddle block anesthesia
    low spinal block
  91. complications of regional anesthesia
    hypotension
  92. most serious complication of regional anesthesia, consequence of vasodilation from sympathetic block and obstructed venous return from uterine compression of vena cava
    hypotension
  93. treatment for hypotension as complication of regional anesthesia
    • Uterine displacement       
    • IV hydration
    • IV bolus ephedrine
  94. Mechanism of action: raises BP by increasing cardiac output. This procedure has totally eliminated or reduced incidence of hypotension
    bolus ephedrine
  95. Used to prevent hypotension
    Preloading - Administration of 500-1000ml IV fluids about 30 min to an hour before the block is done.
  96. Consequence of administration of excessive dose of anesthetic agent
    High spinal blockade
  97. treatment of high spinal blockade
    • Uterine displacement left laterally
    • Tracheal intubation
    • IV fluids and ephedrine to support circulation
  98. Usually due to CSF leak from the puncture site of the meninges,
    Spinal (Postdural Puncture) Headache
  99. pathophysiology of spinal (postdural puncture headache)
    CSF leak from the puncture site of the meninges -> Diminished volume of CSF -> Traction of CNS structures -> Spinal Headache
  100. treatment Spinal (Postdural Puncture) Headache
    • Use small gauge needle
    • Avoid multiple punctures
    • Hydration
    • Epidural blood patch (last resort)
  101. Caused by CSF hypotension
    convulsions
  102. Bladder sensation obtunded and
    bladder emptying can be impaired within the 1st few hours after delivery. Frequent postpartum complication
    bladder dysfunction
  103. Hypertension from ergonovine
    injection is more common in women who receive spinal and epidural blocks. True or False?
    True
  104. Absolute Contraindications to Regional
    Analgesia (Memorize this)
    • Refractory maternal hypotension
    • Maternal coagulopathy
    • Those undergoing treatment with
    • LMW heparin within 12 hours
    • Untreated bacteremia
    • Skin infection over site of needle placement
    • Increased intracranial pressure caused by mass lesion
  105. Relative Contraindications to Regional
    Analgesia
    • Aortic stenosis
    • Pulmonary hypertension
  106. Associated with markedly decreased BP when spinal analgesia is used
    Preeclampsia
  107. Anesthesia of Choice for pre-eclampsia
    Epidural anesthesia ( Incidence of hypotension is much lower than spinal analgesia )
  108. Injection of local anesthesia
    into the epidural or peridural space
    Epidural anesthesia
  109. Difficult intubation due to airway edema
    and CVA due to increased BP
    General Anesthesia
  110. what is the entry of epidural anesthesia?
    • Lumbar intervertebral space
    • Sacral hiatus, or
    • Sacral canal
  111. necessitates block from T10-S5 dermatomes for vaginal delivery
    Continuous lumbar epidural block
  112. necessitates block from T4-S1 dermatomes
    Continuous lumbar epidural block
  113. caused by dural puncture with iadvertent subarachnoid injection
    total spinal blockade
  114. ineffective analgesia risk factors
    • nulliparity
    • heavier fetal weight
    • epidural catheter placement at early cervical dilatation
  115. prevented by rapid infusion of 500-1000ml of crystalloids ( preloading)
    hypotension
  116. most common serious side effect of anesthesia
    hypotension
  117. 2 theories : maternal fetal infection and dysregulation of body temperature
    maternal fever
  118. common complication, transient with no evidence to associate with chronic back pain
    back pain
  119. Prolongs active phase of labor
    for 1 hour
    ↑ need for oxytocin stimulation
    ↑ need for instrumental delivery b/c prolonged 2nd stage labor Additional 30 min to 1 hour
    No adverse neonatal effects
    Continuous lumbar epidural block
  120. some increased duration of 2nd stage of labor by 25 minutes
    Continuous lumbar epidural block
  121. needle-through-needle technique
    combined spinal-epidural techniques
  122. Use subarachnoid opioid bolus with rapid pain relief w/ virtually no motor blockage
    combined spinal-epidural techniques
  123. More rapid pain relief than nepidural analgesia alone
    combined spinal-epidural techniques
  124. Associated with increased maternal morbidity and mortality. Regional anesthesia preferred
    unless contraindicated.
    General Anesthesia
  125. local block that is used to augment an inadequate or patchy regional block
    local infiltration for CS
  126. used to perform emergency CS to save life of a fetus in the absence of any anesthesia support
    local infiltration for CS
  127. LOCAL INFILTRATION FOR CS 
    skin is infiltrated in the line of proposed incision, dilute solution of lidocaine- 30 ml of 2 percent
    1st technique
  128. local infiltration for CS
    field block of the major branches supplying the abdominal wall, 10th, 11th and 12th intercostal nerves
    2nd technique
  129. local infiltration for CS
    skin overlying the planned incision is injected
    3rd technique
  130. common cause of death cited for general anesthesia
    failed intubateion
  131. main cause of maternal mortality
    general anesthesia
  132. patient preparation general anesthesia
    • antacids
    • lateral uterine displacement
    • preoxygenation
  133. favorite IV anesthesia for normal delivery or forceps
    thiopental
  134. easy and rapid induction, prompt recovery, minimal risk of vomiting
    thiopental
  135. poor analgesic agent, administration of sufficient drug given alone to maintain anesthesia may cause appreciable newborn depression
    thiopental
  136. truth serum
    ketamine
  137. useful in women with acute hemorrhage, not associated with hypotension
    ketamine
  138. causes a rise in blood pressure, avoided in women who are hypertension
    ketamine
  139. ms relaxant given to patient to aid intubation, rapid onset and short acting
    succinylcholine
  140. cricoid pressure
    sellick maneuver
  141. alternative for difficult intubation
    LMA ( laryngeal mask airways)
  142. volatile anesthetics
    isoflurane, desflurane, sevoflurane
  143. potent, nonexplosive agents that produce remarkable uterine contraction
    gas anesthetics
  144. used when uterine relaxation is requisite
    internal podalic version of 2nd twin
    breech decomposition
    replacement of acutely inverted uterus
    gas anesthetics
  145. massive gastric acidic inhalation causing pulmonary insufficiency from aspiration pneumonitis
    Mendelson's Syndrome

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