DAILY OR SET UP - ALL 3 ORs CRNA/Resident Sign into Mobile … OB SURVIVAL GUIDE final 2019.pdf · 2019-03-11 · In the setting of IUFD or abruption, ... Anesthesia end for epidurals

LABOR AND DELIVERY ANESTHESIA ORIENTATION MANUAL

Garay/Reviewed/final03.04.2019 pg. 1

DAILY OR SET UP - ALL 3 ORs

To be done by CRNA/Resident coming on duty:

Get sign-out on active and anticipated patients/cases from resident going off duty.

Sign into Mobile Heartbeat TAKE OVER the dynamic role, ensure you are

on the Labor and birth assignment and sign in on White board!

Confirm the Key for the CADD pumps has been returned.

It is your responsibility to make sure all OB operating rooms are properly set

up. This includes:

A. Perform usual room check as you would for any OR/GA, including:

1. Anesthesia Machine check, Check Circuit, standard monitors

2. Check suction

B. Epidural and spinal kits available

C. Jet ventilation apparatus (in pyxis in OR) and ambu bag on side of machine

D. Check drugs: All ready to go in Pyxis

Propofol (10mg/ml), 20ml syringe and unopened 20cc bottle of

propofol

Succinylcholine (20mg/ml), prefilled syringes

Ephedrine (5mg/ml), premixed

Phenylephrine (100mcq/ml) premixed syringes

1. Infusion (100mcq/ml), phenylephrine vial available in

PACU pyxis. Do not premix, supplies available on

shelves.

a. Suggested initiation is 0.5 mcq/kg/min titrate as

needed.

E. Ensure Sigma pump available (2 in each room)

F. Fluid Warmer Rangers (1 in each room) extras in OR hallway

G. Bair Hugger (1 in each room) extras in OR hallway

H. LMA’s sizes 3 and 4 in bottom drawer of machine (Igels also available)

I. Aline intra-operatively:

a. In a box on shelf marked Aline all materials needed to initiate Arterial

line in OR.

Arm boards

Arrows (also in pyxis)

Pressure bags

500 ml of NS

J. Check Glide scope, plug in, manage supplies, clean if used and restock

(supplies located in Anesthesia work room)

a. Difficult airway Cart restock if used located in the back store room)

K. I-STAT located in the work room for anesthesia,

a. Cartridges are located in the workroom refrigerator!!

L. Stethoscope

M. Ether Screen, 1 lug in each room



N. Two arm boards

O. Please replace anything used overnight.

Review Policies:

A. Practice Guidelines for Obstetric Anesthesia (Anesthesiology 2016;

124:270-300)

B. Anticoagulation Policy (SOAP Consensus Statement-Anesth Analg

2018;126:928-44)

C. NPO Policy

D. Piercing Policy (not yet initiated coming soon)

Pre Anesthetic Evaluations

It is the expectation that all patients are seen and evaluated in a timely fashion once

admitted to labor and birth. This includes patients admitted overnight. Following

evaluation, an anesthesia consult note should be entered into EPIC. This is to ensure that

we have an anesthetic plan in place in case of emergency involvement with any of these

parturients.



DAILY EPIDURAL CART CHECK SET UP

To be done by CRNA/Resident coming on duty

In Anesthesia workroom:

1. Lipid rescue: Locate and check expiration date.

2. Epidural Carts: All medications should be stocked by pharmacy during the day. Please

call with medication discrepancies/shortages (Daytime: 200-1681 After 11pm: 688-

1111). All medications are single use vials. Please discard any open vials. Bicarbonate

may be kept for 48 hours if appropriately dated and timed for expiration.

1st DRAWER OF EPIDURAL CART (medications)

1. Phenylephrine (0.1mg/ml) premix syringes

2. Ephedrine (5mg/cc) premix syringes

3rd

DRAWER OF EPIDURAL CART

1. Check Laryngoscope, ETT sizes 6.0, 6.5, 7.0

ON SIDE OF CART

1. Ambu bag

DO NOT ADD ANY MEDS TO OPERATING ROOM PYXIS:

NOTE: The following medications have been added to the OR pyxis:

Toradol

Sugammadex

TXA

Pepcid

EPIDURAL BASICS

1. Consenting parturient – (Written consent with patient sticker, signed and placed with

secretary to be scanned.) Treat the patient just as you would any other anesthetic

evaluation.

Take history: note week of gestation (i.e. 38 weeks), gravida + para status (i.e.

G2 P1), PMH, PSH

allergies, meds

Problems during pregnancy, height, weight

Appropriate labs

Cervical exam, early labor vs close to 2nd

stage

Membranes intact vs SROM vs AROM

Clear or



Meconium

Physical exam:

Airway Exam

Heart Exam

Lung Exam

Discuss epidural + risks: It is prudent to be thorough in discussing risks.

o Bleeding

o Infection

o Nerve injury

o Residual headache (PDPH)

o Hypotension

o Inadequate pain control

o Possibility of block replacement and/or general anesthesia

2. Enter in Pre-op, check labs (*H/H and platelets) at this time and write them in the

H&P. If healthy patient with an uncomplicated pregnancy and no concerns for

PEC/HELLP syndrome, you do not always have to wait for platelet count to come back

(check with the attending). It is helpful to write the H/H especially in case the patient

ends up going for a C-section or bleeding. Recent PT/PTT for patients on anticoagulation,

or bleeding disorders. In the setting of IUFD or abruption, check with your attending if

further laboratory evaluation is warranted prior to block placement.

3. IT IS THE EXPECTATION THAT EVALUATION AND PLACEMENT OCCURS

WITHIN 15 MINUTES OF REQUEST.

3. DOING THE EPIDURAL - Sitting technique

Retrieve cartridge and narcotic bolus from pyxis, also need CADD pump key

Bring epidural cart in room, insure IV is working, pre hydrate (LR or NS),

NBP and ECG monitors in place

PRIOR TO OPENING KIT, RN AND PATIENT SUPPORT PERSON

MUST HAVE HAT AND MASK APPROPRIATELY PLACED AND

PATIENT MUST HAVE HAT IN PLACE.

a Open epidural kit and add ChloraPrep to set up

b Prep-back widely, drape

c Palpate space, 1% lido skin wheal at desired level

d Advance Touhy needle through skin wheal approximately 2-3cm, remove

stylet, attach LOR syringe and advance slowly

e Note when you have loss of resistance and thread catheter 3-5 cm, note some

practitioners use a multi orifice catheter.

Single orifice catheters a minimum of 3cm in the space

Multi-orifice catheters a minimum of 4cm in the space

Give lido/epi test dose unless there is a reason not to (eg: patient is

already hypertensive and you don’t want to give epi or you did a CSE for

a C-section then give test dose prior to dosing epidural catheter): 3cc

lidocaine 1.5% with epinephrine 1:200K after negative aspirate slowly



over 30 seconds. TEST DOSE SHOULD NOT BE GIVEN DURING

CONTRACTION.

Monitor patient for 3-5 minutes after test dose for signs of intrathecal injection

(Sudden analgesia, sudden sensory or motor block) or intravascular injection

(tinnitus, perioral numbness, metallic taste, dizziness, or palpitations) note heart

rate at the beginning of test dose and throughout.

POSITIVE TEST DOSE:

1. An ideal test dose should be a single solution that produces objective evidence of

intravascular or intrathecal injection within several minutes of administration.

2. The test dose for accidental intrathecal catheter placement should produce

relatively rapid sensory changes to allow for easy identification.

Produces detectable sensory block (leg warmth and sensory

loss to pinprick) within 1-2 minutes and a motor block (leg

weakness and impaired straight-leg raise) within 3-4

minutes.

4. The epidural veins of a parturient are larger during pregnancy due to higher

intraabdominal pressures. The incidence of accidental intravascular catheter

placement is about 6% in parturients.

5. Failure to recognize intravenous epidural catheter placement could lead to local

anesthetic systemic toxicity (seizures, cardiac arrest). Using both local anesthetic

and epinephrine in a test dose solution provide different pieces of data to help rule

out intravascular catheter placement.

6. (CNS) toxicity: dizziness, tinnitus, circummoral paresthesia, metallic taste, or

blurred vision. These responses may be unreliable in an anxious parturient.

7. A positive test dose from 15 μg epinephrine results in objective signs: sudden

tachycardia (>10 bpm within 45-60 seconds) and hypertension (increase in systolic

blood pressure by 20 mm Hg).

If negative test dose, tape catheter, aspirate catheter and give loading dose ie

5cc of 0.25% bupivacaine or 10cc of 0.125% in divided doses.

Check sensory level and start infusion

Complete charting, don’t forget to add epidural catheter to LDAs and note

the patient’s vital signs and fetal heart rate throughout.

Patient should be checked 20-30 minutes post insertion of epidural and Q 4

hours while infusion running if no bolus required and Q note written. In Q

note, specify adequacy of pain relief, bilateral block level and mode of check,

presence of motor blockade and further plan such as continue PCEA.

PCEA CASSETTES in pyxis

• Bupivacaine 0.125% with Fentanyl 2mcg/cc. Start 8 ml/hr.

• BE SURE AND PUT A PATIENT LABEL ON EACH ONE.

http://accessanesthesiology.mhmedical.com/drugs.aspx?GbosID=133899








Boluses (For a patient experiencing pain after the epidural placement and boluses are

administered.)

1. Assess nature and location of the pain. Question last cervical exam and the last time

patient had a straight-catheter for urine. Check position of catheter in back.

2. Check sensory level bilaterally.

a This can be accomplished with ice or pinprick technique.

b You may have a one-sided block. Patients can be asked to lie on the side that is

still painful and then bolus. If this does not work, catheter may be pulled back 0.5-

2cm depending on how deep it is compared to where it was left.

3. Choice of local anesthetic for bolus depends on labor progression, parity and

attending preference. 1/8% - 1/4 % Bupivacaine, rarely 2% Lido, depending on the

situation. Discuss with attending if you have any questions.

4. Possible to add 50ug-100ug of Fentanyl to bolus of epidural. Be sure to let the patient

know about temporary pruritus. DISCUSS WITH ATTENDING PRIOR TO

ADMINISTERING EPIDURAL FENTANYL.

5. Chart in room time and assessment of patients for bolus and amount of bolus. Use the

icon in the L&B tab to denote you are in room and place a comment in this block.

Use opposite icon when you leave. This is essential for billing of the epidural is

based on face time interaction.

6. Monitor at least 3 sets of SBPs and always note FHT after and during bolus.

7. If no improvement, check sensory level again and epidural site. The catheter may

have migrated out of the epidural space.

8. If the patient is uncomfortable with an adequate sensory level, notify the obstetric

service for evaluation as not all pain is from contractions.

9. Remember, every dose is a test dose, so administer NO more than 4-5 ml of a local

anesthetic in a single bolus.

AFTER DELIVERY (epidurals)

1. All paper work must be completed.

Anesthesia end for epidurals is placenta delivery (unless we need to medicate for

post procedure or if it’s a CSE for C-section.

C-section end time is as for any surgery. Labor epidural end time if retained

placenta, difficult repair, etc. is at completion of procedure and MUST be noted in

a quick note and in the post op diagnosis/procedure information.

2. Catheter should be removed and this should be documented (including “tip intact and

time stamped”) in chart. Consider awaiting catheter removal pending laboratory

evaluation in patients with known coagulopathy, PEC/HELLP, postpartum hemorrhage,

etc.

3. Pumps should be disconnected and remainder of bag documented and wasted (with

witness).

4. Remove catheter from LDAs and stop infusion at time of placenta delivery if not done so

by nursing staff.



I. STAT C-SECTION with Epidural in Place

1. Note reason for Cesarean delivery (prolonged fetal bradycardia, late decelerations, failure

to progress etc.) and call attending immediately.

2. Administer Bicitra 30cc PO and/or Famotidine 20 mg IV

3. If it is "STAT" take 20 ml syringe of 2% Lidocaine with Epinephrine 1:200,000 and

bicarb. Start giving the Lidocaine quickly in labor room 5ml increments - and watch

patient closely while transporting to OR. THIS IS A SURGICAL ANESTHETIC

WITHOUT MONITORS. Most patients need at least 15 ml of the Lidocaine. Check

level. Be prepared for a STAT general anesthetic if level inadequate. If Chloroprocaine

3% is available, 20 ml can also be used instead of the Lidocaine.

4. Always left uterine displacement and continue the O2 immediately in OR.

5. Once in OR place monitors and start collection of data.

6. Patient can still get fentanyl and or preservative free morphine in epidural. (discuss with

attending and make sure you let surgical team know).

II. STAT C-SECTION without Epidural in Place

1. Call attending immediately.

2. Perform quick history and physical exam. Note the following:

a Airway

b Anesthetic Complications (MH, etc.)

c Allergies

d HTN

e Asthma

f Functional Status

g Coagulation Disorder or use of Anticoagulation

3. Be prepared to do a quick spinal or general anesthesia!

a PLACE OXYGEN FIRST, then monitors.

b Prepare spinal kit

c If GA, draw up all meds and ensure glide scope is in the room.

III. Elective C-section

Primary?

Repeat? If repeat this is number… section?

Many variables and approaches to care.

Spinal vs. CSE vs. Epidural

IV. GENERAL ANESTHESIA FOR STAT C-SECTION

1. Perform H&P as above.

2. Plan for GETA with RSI.



3. Ensure that patient has working IV. Maybe this should be at the start of every encounter

with our parturient.

4. Bicitra premed (recommended but not always administered) and/or Famotidine and

Metoclopramide IV.

* REMEMBER, OB SURGEONS SHOULD BE ALL PREPPED AND

DRAPED, “KNIFE IN HAND” BEFORE INDUCING GA *

5. Pre-oxygenate with good mask fit- 4 vital capacity breaths, cricoid pressure.

6. IV propofol/ketamine/etomidate (depending on clinical status of patient) and

succinylcholine -> intubate.

7. 50% O2 and 50% N2O with halogenated agent, preferably ½-1 MAC (uterine relaxant).

8. (20-30 mg) Vecuronium or Zemuron for paralysis when all 4 twitches have returned.

CHECK WITH ATTENDING PRIOR TO PARALYSIS.

9. Midazolam if needed (after delivery) (high risk for awareness).

10. After baby out, 30% O2, 70% N2O, halogenated agent as low as patients will tolerate,

NO > than 1 MAC, (turn off if atony), fentanyl/dilaudid, +/- propofol gtt., ondansetron.

11. Give neuro-muscular blockade reversal if needed.

12. Extubate awake. Needs to be following commands and able to protect airway. CALL

ATTENDING PRIOR TO EXTUBATION.

V. URGENT C-SECTION with Epidural in Place

1. Ask reason for C-section and call attending.

2. If not truly STAT, take 20 ml syringe of 2% lidocaine with epi and bicarb in anesthesia

refrigerator (workroom). ASK ATTENDING PREFERENCE FOR LABOR

CATHETER LOADING. THIS IS A SURGICAL ANESTHETIC AND SHOULD BE

MONITORED CLOSELY.

3. Give Bicitra premed (recommended but not always administered) and/or Famotidine and

Metoclopramide IV.

4. Most patients will develop adequate level with 15-20 cc lido 2% with epi/bicarb.

5. Be sure to give Preservative Free morphine before removing epidural!! 2-3mg. If BMI

under 40 and no Magnesium Sulfate infusion. Report plan at time out.

6. Put in note for patients receiving neuraxial morphine and communicate in handoff in the

PACU.



VI. URGENT C-SECTION without Epidural in Place

1. Ask reason for C-section and call attending.

2. Bicitra premed (recommended but not always administered) and/or Famotidine and

Metoclopramide IV.”

3. Anesthesia options are spinal/epidural or general depending on situation. Be prepared

for each option as attending decides.

4. Obtain focused history (PMH, any problems with pregnancy [preeclampsia, PIH, etc],

hx anesthesia problems, allergies, etc), NPO status and do airway exam.

5. Confirm working IV and that Pitocin is disconnected from IV.

VII. ELECTIVE C-SECTION

1. Consent patient (see "Epidural Basics")

2. Check NPO status. Consider Famotidine and/or Metoclopramide if recent po intake.

3. Have IV Fluid running wide open. Consider Bicitra 30cc PO or famotidine within 15min

of going to OR.

• If spinal:

1.6-1.8 ml bupivacaine 0.75% with dextrose 8.25%

Fentanyl 10 – 15 ug (0.2cc)

Preservative free morphine 0.1 mg -0.2mg (0.1-0.2ml) (if BMI less

the 40)

Meperidine 10-12.5mg (.2-.25 ml) may also be used if no

preservative free morphine.

Epinephrine (0.1-0.2 mcg) to prolong the block (these are usually

for repeats or for some other complication).

Chronic pain patients: consider clonidine, higher dose IT opioids

• If epidural: lidocaine 2% with epi/bicarb.

4. Communicate if preservative free morphine is used, at the time of time out and to

the RN at the handoff in PACU. There is a special protocol for all these patients

that they follow and how they hand off the patient to the floor.

5. If patient is at risk for postpartum hemorrhage, make sure Type & Screen or Type &

Crossmatch has been sent. Routine standing orders on L&D are for Type & Hold only.

6. All C-section patients must be seen by a resident/CRNA before leaving PACU.

AFTER ALL C-SECTIONS (AND OTHER CASES OCCURING IN THE ORS):

THE ROOM MUST BE TURNED OVER AND RE-SET BEFORE YOU

PROCEED TO ANOTHER PATIENT.

IF ANOTHER ANESTHESIA CARE GIVER OR TECH IS AVAILABLE

HE/SHE MAY HELP.

ROOM TURN OVER ALWAYS TAKES PRIORITY OVER EPIDURAL

PLACEMENTS OR OTHER NON-EMERGENT TASKS.

https://medicine.stonybrookmedicine.edu/anesthesiology/education/OB#Epidural%20Basics




It is hospital policy that no pictures, texting, phone calls or video

recording in the OR!!! If you see a support person with a phone camera

you must/should ask them to put it away or take it until they leave the

Operating Room.

VIII. FORCEPS DELIVERY/SHOULDER DYSTOCIA/PROLAPSED CORD

with Epidural in Place

1. Take 20cc of 2% lidocaine with epi/bicarb or Chloroprocaine 3% in anesthesia

workroom if patient has a block in place.

2. Call your attending.

3. Proceed to patient’s room and communicate with obstetrician about goals of care.

4. Stay with patient until delivery. Remember a failed forceps delivery will likely become

a STAT C-section.

IX. BTL (Bilateral Tubal Ligation)

1. If epidural in place for delivery, working well, and the patient is stable and NPO during

labor, then a BTL can be performed immediately after delivery (if OR and floor

situation are favorable). Give Bicitra 30cc po (provider dependent). Inject epidural with

15- 20cc 2% lidocaine with epi 1:200k to obtain T4-T6 block. Can add fentanyl 50-

100ug via epidural. No preservative free morphine.

2. If patient is NPO and scheduled for BTL post-delivery day 1, then we administer a

spinal anesthetic. Please review H&P, lab data, and postpartum anticoagulation. One can

add fentanyl 10ug to spinal with midazolam IV available. No preservative free

morphine.

3. General anesthesia is not offered for BTLs since it is an elective case. Please consult

with your attending if a patient is refusing a spinal.

CHARTING - VERY IMPORTANT

1. Write pre-op (see "Epidural Basics")

2. Legible Chart

o Be sure to chart a quick note on patients about every 4 hours unless you have been

in the room to bolus. When bolusing make note of stability of VS and FHR.

o Be sure to document top-off meds given and 3 BPs (over 15 min) after the top-off.

o Document fentanyl given and infusion concentration and rate.

3. Post-ops. See and write a brief postop note for all of your patients (EPIC Checklist).

4. Completed anesthesia records.





5. Re-check procedure and postop diagnosis and be sure to remove epidural from

LDA before closing the record and correct/add as needed.

6. AT EVERY SHIFT CHANGE, RESIDENTS/CRNAs MUST SIGN IN TO

RUNNING RECORDS.



OB COMPLICATIONS/ CQI

Any patients who have a wet tap or who contact us postop with headache, nerve problems or any

new problem, need to have an OB (CQI) form completed. These patients will need daily follow

up in person or via phone calls. Notify your attending of these patients. Any patient that has a

problem or complication should be given a business card with the phone number to L&B and

advised to call the anesthesiologist if the problem persists or worsens once she is discharged.

Primary team should be made aware.

1. Intravascular Injection

When testing an epidural needle or catheter placement remember to use only 3cc’s of local

anesthetic, and that every dose is a test dose. The epidural kits come with a 5cc amp of 1.5%

Lidocaine with epinephrine 1:200,000 for testing needle and catheter locations. Should this test

dose with epinephrine be administered inadvertently intravascularly you will notice an

unmistakable rise in maternal heart rate. This will likely be out of proportion to the rise seen

with the pain experienced with impending maternal contractions. Check the maternal heart rate

both before, during and after dosing catheter on the EKG/pulse oximeter tracing. The rise in

heart rate will be instantaneous and unmistakable.

The following symptoms can be noted with an intravascular injection:

• Ringing in the ears

• Dizziness

• Circummoral numbness, or metallic taste in the mouth

• Restlessness or anxiety

• Seizure

If this occurs in the process of placing the catheter, you should replace the catheter. If you are

called to evaluate a patient with an existing catheter, and see any of these symptoms, disconnect

the catheter from the pump and attempt to aspirate the local anesthetic solution. If aspiration is

not possible, hold the end of the catheter below the level of the patient. If obvious blood is seen

with either of these techniques, pull the catheter and place a new one at a new level.

In the event of a known intravascular injection (in dosages greater than a test dose) or if the

patient is symptomatic:

• Stop injecting the epidural

• Call for help STAT

• Have the L&B nurse set up suction and oxygen.

Do not leave the patient to get these items.

• Open the top drawer of the epidural cart and have emergency drugs available.

2. Inadvertent Dural Puncture/”Wet

Taps” Inadvertent dural punctures:

• The first thing to do??? Very dependent on the anesthesia attending on…

some will…

o remove the 17ga Tuohy needle and replace at another level



OR

o thread a intrathecal catheter.

If you remove the Touhy needle and an epidural is necessary,

move to a lower interspace and direct the catheter away from the dural

puncture site.

When dosing the catheter, only small amounts of local

anesthetic should be used initially to rule out the possibility of a dural

communication. All further catheter dosages at this point should be

treated as test dosages and hence be limited to 3cc increments.

If you leave the catheter…

• Additional IV fluids may be necessary Write clearly

on the patients record that a “wet tap” occurred. Make sure

you label the catheter as “intrathecal or spinal”. Some

attendings prefer to knot the cathter before sending the patient

to the floor and keeping it in place for 24 hours. It is the

responsibility of the obstetric anesthesia team to remove it at

that time.

• Inform the patient about the possibility of a headache,

which you have already done as part of the informed consent

process, give patient an OB Anesthesia business card. • Once the patient is comfortable and before you leave the

room you must discuss wet tap and inform her of process for

followup post partum. 3. Hypotension

If the patient gets sick after you initiate a spinal or epidural block for c-section.

Hypotension is the most common side effect of local anesthetic in the epidural or

subarachnoid space. Ephedrine was traditionally the pressor of choice in obstetrical

anesthesia. However, recent studies has shown Neosynephrine to be a far

superior choice for the treatment of maternal hypotension. This is clearly

demonstrated in a 2009 study in Anesthesiology by Nhan

“Placental transfer and fetal metabolic effects of phenylephrine and ephedrine

during spinal anesthesia for cesarean delivery”. The conclusion is that ephedrine

crosses the placenta to a greater extent and undergoes less early metabolism and/or

redistribution in the fetus than phenylephrine. The associated increased fetal

concentrations of lactate, glucose, and catecholamines support the hypothesis that

depression of fetal pH and base excess with ephedrine is related to metabolic

effects secondary to stimulation of beta-adrenergic receptors. Despite historical

evidence suggesting uteroplacental blood flow may be better maintained with

ephedrine, the overall effect of the vasopressors on fetal oxygen supply favors

phenylephrine.

Treatment pearls:

o Phenylephrine infusion is the standard of care following neuraxial anesthesia for cesarean

section. The usual dose is 0.5mcg/kg/min starting and should be titrated to effect.



Consider changing dose for patients with HTN/PEC, etc. Give phenylephrine before the

BP declines >20%. Watch the trend! Prophylactic treatment dosages are lower.

The prophylactic dose is 25-50mcg. If you get a secondary bradycardia, than

switch to Ephedrine, but go back to Phenylephrine as soon as the maternal heart

rate picks back up! o

o Sudden tachycardia is a hypotension precursor. Don’t wait for the cuff-give to

cycle to give phenylephrine. Follow the trends. If the patient tells you they are

nauseated or feel like they are going to get sick- stop what you are doing.

Immediately provide prophylactic treatment, then cycle the cuff. Stay on top of it

and they will not get sick. (SBP cuff should cycle every one minute until delivery

of fetus and or regulation of SBP).

o PEARL: ADMINSTERING THE ANCEF IN A BOLUS ALSO LEADS TO

NAUSEA/VOMITING. Please give it slowly over several minutes.

o If you are called to evaluate hypotension, or it occurs after placement of an

epidural:

1. Confirm left uterine displacement and evaluate the patient for

sympathectomy symptoms (n/v, dizzy, light-headed, motor blockade).

2. Confirm blood pressure again, ask yourself what is the patient’s baseline

pressure? Of course you noted this on your pre-anesthetic assessment.

3. If hypotensive (greater than 20% drop in systolic blood pressure) or SBP

<100mmHg, give Neosynephrine 50-100mcg or Ephedrine 5-10mg and a

fluid bolus. Consider oxygen by mask.

4. Check the patient’s level and evaluate reason for hypotension (ex.

inadequate preload, excess dose of anesthetic with excess level,

inadvertent spinal placement, poor maternal positioning).

5. Apply corrective measures after etiology of hypotension is known.

4. Asymmetric Sensory Block and “Windows”

Asymmetric block

• If the patient lies continuously on one side, the level of sensory block may

become asymmetric and the nondependent side may become painful as the local

anesthetic gravitated to the dependent side. The situation should be corrected by:

repositioning the patient to the side without the block and administering 5-6cc’s of

the 0.25% Bupivacaine or 0.125% Bupivacaine 8-10 ml (attending preference).

• “Windows” are defined by an area that lacks analgesia (the patient can and will

tell you exactly where it is) and is surrounded by areas that are anesthetized. For

resistant windows:

o 0.375% Bupivacaine (by combining equal volumes of 0.25% and 0.5%

o Bupivacaine, give 4-7 mls

o 0.25% Bupivicaine with epi 5 ml

o 0.125% Bupivicaine with epi 5-8 mls o Fentanyl 100mcg (Do not administer more frequently than q4hrs)



5. Spinal Headache/Post Dural Puncture Headache (PDPH)

Whether the patient is at the hospital or home, obtain and review the chart: evaluate

needle type and size, difficulty of placement, ? wet tap. If you are comfortable

doing so, inform the individual who performed the block.

Ask the patient to describe the headache:

• Is it positional?

• Could it be due to meningitis (nuccal rigidity, meningeal signs) Neurologic

disturbances (visual or auditory)? Postpartum PEC? Intracranial Pathology?

• Evaluate the positional nature of the headache.

• Examine the spinal/epidural injection site.

• Check and inquire about the conservative management for 24-48 hours.

o IV hydration continued

o Fioricet ordered and scheduled not PRN alternating

o With Motrin scheduled

o Encourage PO intake with and without caffeine.

Prophylactic measure in the treatment of inadvertent dural puncture headache is to thread an

epidural catheter into the dura (when the initial wet tap occurred) and leave it there for 24 to

48 hours. It should be clearly marked “spinal catheter” and it’s injection port should be

taped closed. The reason for threading a catheter into the dura is to tamponade or plug the

dural tear with epidural catheter preventing CSF loss as well as inducing a “local” immune

reaction to the catheter/dura interface resulting in a physiologic “plug”. In this situation, the

patient has spinal anesthesia for labor. The catheter is removed in 24 hours. THIS IS

ATTENDING DEPENDENT. Other treatment measures that could be applied include: an epidural blood patch and

sphenopalatine blocks. Not all headaches necessitate a blood patch. A blood patch is not a

harmless procedure. It is after all, the creation of an epidural hematoma which under most

circumstances is a surgical emergency.

Blood Patch Procedure:

An epidural blood patch is a procedure to treat a headache caused by leaking

cerebrospinal fluid (CSF), an epidural for labor and delivery and sometimes although rare

after a spinal (especially in thinner patients).

The blood patch involves injecting a small amount of blood into the epidural space

around the spinal canal, near the site of the previous puncture. As the blood clots, it

forms a “patch” that seals the site and stops the leak of CSF.

The following patients should not have this injection: patients on blood thinners (ie.

Coumadin, heparin, lovenox), or if patient has an active infection.



Procedure risks are the same as the laboring epidural and also include inadequate

resolution of headache and requirement for additional treatment or blood patch.

The procedure is also the same, you will need a large bore IV to withdraw the blood with

sterile technique, also instead of threading catheter you will be injecting blood, in small

increments (5-10 mls up to 20ml or until patient has back pain or intense back pressure).

After a blood patch, patient remains flat for 30-60 minutes, then elevate 15degrees, assess

V.S. continue this in slow increments.

It is recommended that in addition to the above mentioned treatments the patient should

be encouraged to avoid straining, rapid breathing, bearing down or lifting heavy objects.

They should also be given the yellow discharge instruction sheet from anesthesia after

reviewing it with patients and support person. Also ensure they know the number to call

with questions and concerns.

A procedure and encounter is made in epic for charting.

Also discharge orders must be placed.

These patients should be seen or called for follow up over the next several days with

progression of symptoms documented.

OB CONSULTS

Often obstetricians notify us about a high-risk patient that needs an anesthesia consult

prior to term. If an OB attending or resident asks you to see a consult patient, please

notify your attending. A formal consult needs to be done with evaluation by resident and

attending.

DRUGS IN L&B Pitocin

Not as innocuous as you think it is!

In a cesarean section, NO Pitocin should be attached to patient’s IV or hanging on an IV

pole until the infant is delivered.

Associated with significant adverse events.

o Maternal arrhythmias, hypotension, uterine hyper stimulation, hyponatremia. It is a

cardiac depressant and vasodilator.

o Fetal decreases in oxygen saturation r/t contraction frequency, neonatal seizures,

hyperbilirubinemia, and/or retinal hemorrhage have been reported following

oxytocin use.

Oxytocin remains the drug most commonly associated with preventable adverse events

during childbirth, and the drug implicated in nearly half of all paid obstetric litigation

claims.

Common clinical practices result in unnecessary, excessive oxytocin doses. In non

laboring women undergoing cesarean delivery, a ceiling effect of oxytocin 5u is

witnessed, beyond which no further improvements in uterine tone and blood loss is

observed.



Women who receive oxytocin for augmentation of labor have greater blood loss despite

higher oxytocin doses; this appears to originate from signal attenuation and

desensitization of the oxytocin receptors, in a time and concentration dependent manner.

Expect need for use of other uterotonic medications.

Magnesium Sulfate

This is used as: You should be aware of the indication for its use!!

1. A tocolytic

2. For fetal brain protection if preterm delivery is anticipated

3. For PEC with severe feature

Maternal: Magnesium sulfate is given only intravenously. A woman is given an initial

infusion of 4 to 6 grams over 15 to 30 minutes, and then a maintenance dose of 2 to 3

grams per hour.

Plasma levels should be checked to avoid toxicity.

High doses, magnesium sulfate can cause cardiac arrest and respiratory failure.

Magnesium is primarily renally cleared and may build in patients with worsening

renal function.

Treatment of Magnesium Toxicity: Calcium Chloride (Calcium Gluconate if CaCl

unavailable.)

Most common signs that nurses watch for is the loss of the knee-jerk reflex

Fetal: Since magnesium sulfate relaxes most muscles, babies who have been exposed to

magnesium for an extended period of time may be listless or floppy at birth.

This effect typically goes away as the drug clears from the baby's system.

Available evidence suggests that magnesium sulfate given before anticipated early

preterm birth reduces the risk of cerebral palsy in surviving infants. Magnesium sulfate

for fetal neuroprotection should develop specific guidelines regarding inclusion criteria,

treatment regimens, concurrent tocolysis, and monitoring in accordance with one of the

larger trials.

KNOW THE INDICATION AS MANAGEMENT DURING CESAREAN

DELIVERY IS DIFFERENT FOR EACH INDICATION.

PATIENTS ON MAGNESIUM SHOULD HAVE A DEDICATED IV FOR THIS

TREATMENT TO PREVENT BOLUS OF LARGE VOLUMES.

Ketamine: (used for inductions of GA)

Methergine:

Following delivery of the placenta, for routine management of uterine atony,

hemorrhage, and sub involution of the uterus. For control of uterine hemorrhage in the

second stage of labor following delivery of the anterior shoulder.

IM: 0.2mg after delivery of the anterior shoulder, after delivery of the placenta, or during

the puerperium; may be repeated as required at intervals of 2–4 hours.

Contraindications: Hypertension. Preeclampsia/Eclampsia. Pregnancy (Category.C).



Hemabate:

Dose: 250mcg q15 minutes for total of 8 doses.

Administered IM: stimulates in the gravid uterus myometrial contractions similar to labor

contractions at the end of a full term pregnancy. o Postpartum, the resultant myometrial

contractions provide hemostasis at the site of placentation. o Use with caution with asthmatic patients.

Misoprostol:

Dose 400mcg bucally or 1000mcg PR.

Misoprostol (marketed as Cytotec). For pregnant women who may receive misoprostol to

soften their cervix or induce contractions to begin labor. Misoprostol is sometimes used to decrease blood loss after delivery of a baby.

Nitroglycerin:

Nitroglycerin produces rapid effective uterine relaxation. o It may be given in 50-100ug increments for retained placenta, or in larger doses

for correction of uterine inversion. Also chase with phenylephrine bolus.

Lipid rescue:

Lipid Rescue resuscitation refers to the intravascular infusion of 20% lipid emulsion

to treat severe, systemic drug toxicity or poisoning. Lipid Rescue was originally

developed to treat local anesthetic toxicity, a potentially fatal complication of

regional anesthesia.

See information sheet in anesthesia office and workroom.

Contraindications to Regional Anesthesia/Analgesia

Absolute Contraindications:

• Patient refusal

• Infection at the site of needle insertion

• Hypovolemic shock/active hemorrhage

• Coagulopathy

• Acute CNS disease

Relative Contraindications

• Pre-existing neurologic disease of the spinal cord or peripheral nerves.

• Anticoagulation limitations are based on timing of last dose and laboratory

evaluation. Please review SOAP Consensus Statement.

• Chorioamnionitis/prolonged rupture of membranes- regional anesthesia is

probably safe if the patient does not appear clinically septic (rigors, fever >101),

has received appropriate antibiotic coverage prior to initiation of the regional

block and that the patient has demonstrated clinical evidence of a positive



response to antibiotic treatment as manifested by a decline in maternal

temperature.

Common High Risk Diagnoses in the Parturient:

Maternal Age

Women who will be under age 17 or over age 35 when their baby is due are at

greater risk of complications than those between their late teens and early 30s.

The risk of miscarriage and genetic defects further increases after age 40.

Preeclampsia/PEC

A syndrome that includes high blood pressure, proteinuria, and end organ

dysfuction. Edema may be present but it’s not considered diagnostic. It can be

dangerous or even fatal for the mother or baby if not treated. With proper

management, however, most women who develop preeclampsia have healthy

babies.

http://teens.webmd.com/default.htm



http://www.webmd.com/baby/guide/pregnancy-miscarriage



http://www.webmd.com/baby/guide/preeclampsia-eclampsia

http://www.webmd.com/hypertension-high-blood-pressure/ss/slideshow-hypertension-overview

http://www.webmd.com/hypertension-high-blood-pressure/ss/slideshow-hypertension-overview



Medical conditions that occur during pregnancy.

Pregnancy-related issues. Often a pregnancy is classified as high risk because of issues that arise from the pregnancy itself and that have little to do with the mother's health.

Gestational diabetes is a type of diabetes that develops during pregnancy. Women

with gestational diabetes may have healthy pregnancies and babies if they follow

the treatment plan from their health-care provider. Usually the diabetes resolves

after delivery. However women with gestational diabetes are at increased risk of

developing type 2 diabetes.

Premature labor is labor that begins before 37 weeks of pregnancy. Although

there is no way to know which women will experience preterm labor or birth,

there are factors that place women at higher risk, such as certain infections, a

shortened cervix, or previous preterm birth.

Multiple births means you are carrying more than one baby (twins, triplets,

quadruplets, etc.). Multiple pregnancies, which are more common as women are

using more infertility treatments, increase the risk of premature labor, gestational

diabetes, and pregnancy-induced high blood pressure.

Placenta previa is a condition in which the placenta covers the cervix. The

condition can cause bleeding, especially if a woman has contractions. If the

placenta still covers the cervix close to delivery, the doctor may schedule a

cesarean section to reduce bleeding risks to the mother and baby.

Fetal problems, which can sometimes be seen on ultrasound. Approximately 2%

to 3% of all babies have a minor or major structural problem in development.

Sometimes there may be a family history of fetal problems, but other times these

problems are completely unexpected.

Other Diagnosis Contributing to high risk pregnancies

Maternal Systemic Disease

MORBID OBESITY

Many of the anatomic and physiologic changes of pregnancy are accentuated by obesity. Chest

wall compliance is decreased. Oxygen consumption and carbon dioxide production are increased

further. Lung volumes are further decreased in obese parturient

ASTHMA

• Asthma is becoming more prevalent in the general and pregnant population.

• During labor and delivery, high-dose opioid analgesia may cause respiratory depression

and decompensation in a wheezing patient.

http://www.webmd.com/diabetes/gestational-diabetes-guide/gestational_diabetes

http://www.webmd.com/diabetes/gestational-diabetes-guide/gestational_diabetes

http://www.webmd.com/diabetes/guide/types-of-diabetes-mellitus



http://www.webmd.com/diabetes/diabetes-health-check/default.htm



http://diabetes.webmd.com/guide/diabetes_symptoms_types



http://www.webmd.com/baby/premature-labor

http://www.webmd.com/baby/premature-labor

http://www.webmd.com/women/picture-of-the-cervix



http://www.webmd.com/infertility-and-reproduction/guide/infertility-reproduction-treatment-care



http://www.webmd.com/hypertension-high-blood-pressure/hypertension-assessment/default.htm



http://www.webmd.com/baby/understanding-placenta-previa-basics

http://www.webmd.com/baby/understanding-placenta-previa-basics

http://www.webmd.com/baby/guide/normal-labor-and-delivery-process



http://www.webmd.com/baby/guide/cesarean-section-topic-overview




http://www.webmd.com/a-to-z-guides/what-is-an-ultrasound





OBSTRUCTIVE SLEEP APNEA

Sleep apnea can be either obstructive or central. Normal sleep is a state of rousable

unconsciousness. Arousal protects apneic patients from further hypoxemia and hypercarbia.

CARDIOVASCULAR DISEASE

Women may present in pregnancy with corrected, partially corrected, or uncorrected lesions. A

referral for an anesthesiology consult prior to delivery is indicated. A multidisciplinary team

approach involving the obstetrician, cardiologist, and anesthesiologist may provide the best

maternal and fetal outcomes.

SICKLE CELL DISEASE

Epidural labor analgesia may aid in the care of the laboring patient with sickle cell disease in

several ways. Pain control is of obvious importance in the patient with sickle cell disease.

Epidural analgesia to manage pain during a sickle crisis that occurred during labor has been

described. An additional advantage is that epidural blockade is associated with decreased

peripheral venous stasis.

COAGULATION DISORDERS

Patients with hypercoagulable states, for example, protein C deficiency, protein S deficiency,

antithrombin III deficiency or Leiden factor V, may be receiving either prophylactic or

therapeutic doses of heparin.

MUSCULOSKELETAL DISORDERS

Malignant hyperthermia

Malignant hyperthermia is a hypermetabolic disease of skeletal muscle that is triggered in

genetically susceptible people by exposure to volatile anesthetic agents or succinylcholine. It

is life-threatening if a crisis is not recognized and treated appropriately. A history of

malignant hyperthermia susceptibility in the parturient or her family should prompt an

antenatal interview with an anesthesiologist.

INFECTIOUS DISEASE

Neuraxial analgesia/anesthesia is contraindicated in the presence of systemic infection (risk of

hematogenous spread if the procedure is performed during bacteremia or viremia) or local

infection at the site of skin puncture.



Herpes Simplex Virus

Patients with symptomatic herpes simplex virus type 2 (HSV-2) often present for cesarean

delivery.

SUBSTANCE ABUSE

• Many drugs, both legal and illegal, have the potential to adversely impact the anesthetic

care of a patient.

• There are increased risks to both general and neuraxial anesthesia in cocaine-abusing

parturients. General anesthesia is associated with a higher risk of severe hypertension and

dysrhythmias.

AMPHETAMINES

As with cocaine, general anesthesia is associated with hypertension and dysrhythmias.

OPIOIDS

Long-term opioid use affects the administration of analgesia/anesthesia in several ways. The

parturient's baseline opioid use should be calculated and administered to prevent maternal and

neonatal withdrawal. Treatment of labor pain, or postoperative pain, will require additional doses

of opioid. Neuraxial analgesic/anesthetic techniques may be advantageous for the opioid addict

because analgesia can be provided with local anesthetics (without opioids). As with cocaine

abuse, apparently adequate regional anesthesia may not provide acceptable pain relief in some

opioid users. Finally, intravenous drug users have an increased risk of spontaneous epidural

abscess.

CANNABIS

Cannabis may enhance the sedative–hypnotic effects of other central nervous system

depressants. It impairs lung function in a manner similar to tobacco. Acute cannabis intoxication

has been associated with uvular edema and airway obstruction after general anesthesia.

ENDOCRINE DISEASE

Diabetic parturients

Hypothyroidism

Pregnant women with pheochromocytoma may require tumor resection early in pregnancy or

cesarean delivery followed by tumor resection. General, neuraxial and combined anesthetic

techniques have been used successfully for tumor resection, but no randomized study has been

performed.

http://www.glowm.com/section_view/heading/Anesthesia%20in%20High-Risk%20Obstetrics/item/217#r116



NEUROLOGIC AND NEUROMUSCULAR DISORDERS

Epilepsy

Many anticonvulsants induce hepatic liver enzymes and affect the metabolism of other drugs,

including drugs commonly used in the administration of anesthesia. In addition, these women

may be at risk for deficiency in their vitamin K-dependent clotting factors.

Spinal Cord Injury

Women with spinal cord injuries above the level of T7 to T5 are at risk for autonomic

hyperreflexia during labor and delivery. Neuraxial anesthesia with local anesthetic agents is

recommended to prevent labor-induced autonomic hyperreflexia.

Documents

DAILY OR SET UP - ALL 3 ORs CRNA/Resident Sign into Mobile … OB SURVIVAL GUIDE final 2019.pdf · 2019-03-11 · In the setting of IUFD or abruption, ... Anesthesia end for epidurals