OBSTETRICANESTHESIARESIDENTHANDBOOK

RESIDENTSCHEDULE OPERATINGROOMSETUP PREANESTHETICEVALUATION HIGHRISKCONSULTSERVICE ASEPTICTECHNIQUE EPIDURALPLACEMENTANDMAINTENANCE COMBINEDSPINALEPIDURAL(CSE)PLACEMENT CESAREANDELIVERYWITHINSITUEPIDURAL TOPPINGOFFLABOREPIDURALS CATHETERPULLS SUBARACHNOIDBLOCKS COMPLICATIONSOFNEURAXIALTECHNIQUES OBSTETRICANESTHESIACURRICULUM

RESIDENTSCHEDULE Theresidentscheduleisasfollows:onmonthswhen2residentsarerotatingonthe service,onewillbedesignatedthea.m.residentandtheotherwillbethep.m. resident.Thea.m.residentshouldarrivenolaterthan6:45andwillstayuntil3p.m.; theotherresidentwillarriveat11a.m.andstayuntil7p.m.Thereisoftenaflurry ofepiduralplacementsbetween6:30and7:00a.m.,sotheearlyresidentmight considercomingearlierwhenpossible. Eachweekthea.m.andp.m.residentwillalternate.Youareresponsibleforagreeing whowillbethea.m.andp.m.residentthefirstweekandforalternatingthereafter. Thefirstdayontheservicebothresidentscanarriveat6:45sothatthemoresenior residentcanorienttheother.Whenonlyoneresidentisontherotation,he/she shouldarrivenolaterthan6:45a.m.andstayuntil5p.m.Inthenearfuture,we hopetohaveovernightcallfacilitiesforresidents,andatthattimewewilltweakthe scheduleonceagaintoensureoptimalexposuretoproceduresontheL&Dward. PleasenotethatyouareresponsibleforcontactingbothPattyBurkeandthestaff memberonL&Difyouhaveanunanticipatedemergencyorillnessandareunableto gettowork.Thesameappliesifyourequestanadditionalvacationdaythatwasnot originallyscheduled. Whenthea.m.residentarrives,he/sheshouldchecktheanesthesiamachineand ensurethatemergencydrugsandequipmentfortheadministrationofageneral anestheticareimmediatelyavailable.Thecasesforthedayareusuallypostedonthe whitebulletinboard;scheduledlaborinductionsarelistedinabinderatthenursing stationor,ifthepatientisalreadyinhouse,onthebulletinboard.TheCRNAonL&D canalsoprovideupdatesforthedaysschedule. Dailyresidentdutiesinclude:attendthesafetyroundsat7:30a.m.eachmorning inthe2ndfloorneonatalconferenceroom,whenpossible;filloutthepreanesthesia evaluationpapersoneachpatientrequestinganepiduralorscheduledforCesarean delivery,cerclage,tuballigation,etc.(thepacketofpapersisusuallyinthepatients chartorontheclipboardintheanesthesiaworkroom);placeepiduralsonce properlytrainedandprepared,andfilloutalltherelevantpaperwork;troubleshoot andtopoffepidurals,asneeded;provideneuraxialorgeneralanesthesiafor operativeprocedures,remainingwiththepatientandchartingappropriately throughout;attendalllecturesofferedbystaff,colleagues,andfellows;perform postoperativevisitsonallpatientsfromtheprecedingday(alistofpatientswillbe provided);andprovidecontinuityofcareforallantepartumpatients(thesearethe patientsbeingobservedonthefloorwhosestatusshouldbereassessedonadaily basis).Iftworesidentsareavailableduringthehoursbetween11a.m.and3p.m. (whenshiftsoverlap),onewillbeexpectedtorunthefloor,placingand troubleshootingepidurals,whiletheotherisinchargeofsurgicalcases.Antepartum andpostpartumvisitscanbedividedbetweenresidents,orresidentscanalternate thesedutiesweekbyweek.

Inadditiontotheaboveduties,eachresidentisresponsibleformakinga PowerPointonasubjectofinterestforpresentationduringthefinalweekonthe rotation.WewillalsoassignaseriesofJackpotquestionsatthebeginningofthe rotation;weexpectyoutoresearchtheanswersandbepreparedtoanswerthese questionsatadesignatedJackpotanswersessioneachweek(belowisalistof resourcestoaidinyourresearch).Further,whentimepermits,youwillbeexpected totakeoversurgicalproceduresalreadyunderway,relievingtheCRNAand assumingresponsibilityforthoseobstetricpatientsintheoperatingsuites.Finally, occasionallyyouwillbeaskedtoperformpreoperativeassessmentsonbothhigh riskparturientsandnonobstetricpatientsscheduledforoutpatientsurgeryat TulaneLakesideintheanesthesiapreoperativeevaluationcliniconthe1stfloor. Thesepreoperativeevaluationsrequireyourfamiliaritywithpreoperative guidelines,anestheticimplicationsofavarietyofdiseaseprocesses,andwith furtherworkupalgorithmsthatmightbenecessarytooptimizeapatientfor surgery.Thepreoperativeevaluationclinicprovidesagoodlearningopportunity, particularlyinpreparationfortheOralBoards. TheL&Dwardismarkedbypeaksandlulls;residentsshouldtakeadvantageof downtimebystudying,reading,preparingthefinalPowerPointpresentation,and answeringtheJackpotquestions.Thethirdfloorofficehasseveraltextsand questionbooks,aswellasthreecomputerswithPowerPointcapacity.Pleasetake advantageofthesefacilitiesforstudy,research,etc. Finally,averyinformativeandrecentlyupdatedreferencebooktohelpguideyou duringthisrotationisObstetricAnesthesiaHandbookbySanjayDatta,Bhavani ShankarKodali,andScottSegal.ItisavailableatAmazonandotheronline companies.Youshouldalsobeintimatelyfamiliarwiththe2007ASAPractice GuidelinesforObstetricAnesthesia(seeAnesthesiology2007;106:84363orsimply GoogleASAObstetricAnesthesiaGuidelines;theseguidelinesarealsoprintedin thebackofChestnutsObstetricAnesthesiatext).Otherresourcesyoumayfind helpfulinclude:ChestnutsObstetricAnesthesia:PrinciplesandPractice,4thEd; ClinicalAnesthesiologybyMorgan,MikhailandMurray(withparticularemphasison theLocalAnestheticsandObstetricAnesthesiachapters);andAnesthesiaReview:A StudyGuidetoAnesthesiaandBasicsofAnesthesiabyLorraineSdralesandRonald Miller(again,withemphasisontheLocalAnestheticsandObstetricAnesthesia chapters).Theseandothertexts,includingLongneckersAnesthesiology,Millers Anesthesia:2VolumeSet,andBarashsClinicalAnesthesiaareinthe3rdflooroffice, althoughIencourageyoutopurchasetheObstetricAnesthesiaHandbook. OPERATINGROOMSETUP Eachmorningandaftereachcase,theanesthesiamachineandallequipmentmust becheckedandleftreadyforanyemergencythatmightarise. Thefollowingitemsmustbeimmediatelyavailableandreadytouse:

 Anesthesiamachinewithbreathingcircuit(thathasbeentestedforleaks)and mask BPcuff,EKG,andSpO2cable Laryngoscopesandblades(besuretocheckeachhandleandblade) StylettedETTofallsizes(6.0,6.5,7.0) Immediatelyavailableephedrine,phenylephrine,andsuccinylcholine.Atropine, glycopyrrolate,andepinephrineshouldbereadilyaccessible Asecure,readilyavailableinductionagentandsyringe Workingsuctionwithtipattached Ambubag Oralairways Stethoscope Afullystockedobstetrichemorrhagecartanddifficultairwaycartareimmediately availableintheORcommonarea PREANESTHETICEVALUATION PatientsontheL&Dflooraretobeseenandevaluateduponnurseorobstetrician request.Inaddition,weoftenelecttoevaluateallpatientsconsideredhighriskas soonaspossible,includingpatientsscheduledfortrialoflaborafterCesarean (TOLAC),obesepatients,patientswithknownorsuspecteddifficultairways, multiplegestationparturients,severepreeclamptics,etc. AfocusedH&Pshouldincludeage,gravidandparastate,weeksgestation,any complicationsofcurrentpregnancy,reasonforC/S(ifapplicable),reasonforprior C/S(ifapplicable),previousanesthetics,height,weight,allergies,comorbidities, airway,heartandlungexamination,anyrelevantlabs(plateletsforapatientwith knowngestationalthrombocytopenia,plateletdisorder,HELLP,orclinicalhistoryof bleeding;urineproteinforpatientswithpreeclampsia;bloodglucoseforpatient withDM,etc.),NPOstatus,andanestheticassessmentandplan.Abaselinematernal bloodpressureandfetalhearttones(FHTs)shouldalsobedocumented. Forreviewofsystems,itisimportanttoevaluatewhetherpatientswith preeclampsiahavevisualchanges,edema,abdominalpain,headache,oranysignsof easybleeding/bruising.AskallparturientsaboutGERD,aswellasn/v,SOB,CP,and palpitations,whenappropriate. HIGHRISKCONSULTSERVICE InconcertwiththeObstetricsDepartment,werecentlylaunchedahighriskconsult service.Obstetricianshavebeenaskedtoidentifyparturientsconsideredhighrisk andsendthemforananesthesiaconsultinadvanceoftheestimateddateof confinement(EDC).Highriskpatientsinclude,amongothers,supermorbidlyobese womenwithothercomorbidities,patientswithseverescoliosis,patientsatriskfor hemorrhage(previa,accreta,percreta,forexample),patientswithbleeding disordersorcongenitalheartdisease,etc.Thisconsultservicealsogivesusan

opportunitytomeetpatientswithanesthesiaconcerns,includingthosewitha historyofdifficultepiduralplacement,inadvance.Ourgoalistoassessthese patients,orderanyrelevantconsultsorfurtherworkup,andcraftananesthetic assessmentandplan,which,inturn,willbecirculatedamongallrelevantparties. Residentswill,onoccasion,beaskedtoconductafullH&Ponhighriskpatientsin thepreoperativeevaluationcliniconthe1stflooratTulaneLakeside,presenttheir findingstothestafforfellow,anddictateareport.Wewillprovideatemplatefor dictationandensureaccesstothedictationservices. Importantly,remembertoaskthepatienttoinformtheanesthesiologistthatshe wasseeninthehighriskclinicwhenshecomesinforherdelivery.Also,recordthe nameoftheobstetricianontheH&P,thepatientstelephonenumber(intheevent thatwehavetocontactherforfollowup),andtheEDContheH&P.Wehave separatebindersforhighriskpatients,boththosetobedeliveredandthose alreadydelivered,intheanesthesiastockroomontheL&Dfloor.Printedcopiesof ourdictationorofourH&Paretobeplacedinalphabeticorderinthetobe deliveredbinderuntilthepatientpresentsfordelivery,atwhichtimewecanpull thecopiesandattachthemtothepatientsclipboard. ASEPTICTECHNIQUE Infectiouscomplicationsofneuraxialtechniquesarerare,butontherise.The causativeorganisminthecaseofmeningitisismostoftentracedtothe nasopharnygealbacteria(specifically,alphahemolyticstreptococci)ofthe anesthesiaprovider.Asaresult,itisconsideredstandardofcaretowearamask,as wellassterileglovesandascrubhat,whileperformingneuraxialprocedures.Itis alsoreasonabletoconsiderroutinelyplacingacaponthepatient.Chloroprephas beenproventobesuperiortoBetadineintermsofitsbactericidalproperties.Itis notyetavailablein(orFDAapprovedfor)spinalandepiduralkits,butcanbe droppedontoyouropensterilefieldifyouprefertouseitforpreppingthepatients back.Finally,handwashinghasbeenshowntobethemosteffectivewaytoprevent thespreadofnosocomialinfection;changingglovesisnotasubstituteforwashing handswitheachnewpatientcontact.Formoreinformation,pleaserefertoTerese HorlockerandDeniseWedelsInfectiouscomplicationsofregionalanesthesiain BestPractice&ResearchClinicalAnaesthesiologyVol.22,No.3,pp.451475,2008. EPIDURALPLACEMENTANDMAINTENANCE AfteryourH&Piscompleteandyouhavewithdrawntheappropriateepidural medications(morebelow)andpressors(ephedrineandphenylephrine),rolloneof thetwoepiduralcartsintothepatientsroom(onecartislocatedintheanesthesia stockroom;theotherisinthecommonareabetweentheORs).Makesurethatthe cartisproperlystockedbeforeusingit.Theepiduralsolutionof0.1%bupivacaine with2mcg/mLoffentanylandtheephedrinearelocatedinthePyxisintheOR commonarea.Premadesyringesofaloadingdosearelocatedintheanesthesia stockroom,alongwithapremadesolutionofphenylephrineataconcentrationof 100mcg/mL.

 ConfirmthatthepatienthasaworkingIVandconsidereitheracrystalloidpreload (thisiscontroversialpleaserefertotheASAObstetricAnesthesiaGuidelinesand toyourattendingstaffsclinicaljudgment)orcoload. Althoughwedonotroutinelyadministeraspirationprophylaxisforepidural placement,itisreasonabletoconsidergivingBicitra30mLPObeforestarting, particularlyifthereisanyconcernthatthepatientmaygoforanurgent/emergent Cesareandelivery(forexample,ifthereisfetaldistressorimminentbreech delivery). Nursingguidelines(AWHONN)statethatanurseshouldbepresentduringall epiduralplacementsinordertomonitorboththemotherandthefetusandinthe eventofunanticipatedcomplications.TheASAObstetricAnesthesiaguidelinesstate: thefetalheartrateshouldbemonitoredbyaqualifiedindividualbeforeandafter administrationofneuraxialanalgesiaforlabor. Washhands;weargloves,hatandmask. Thepatientcanbeplacedineitherlateralorseatedpositionduringplacement.The formermayprovidegreatercomfort,decreasepatientmovement,anddecreasethe incidenceofintravascularcannulation,whilethelatterpositionmayfacilitate visualizationofthepatientsanatomicallandmarks. OurepiduralkitsareequippedwithTuohyneedles(wecurrentlystockboth17G and18Gneedles);eitherlossofresistancetoairorsaline(peryourcomfortlevel andyourstaffspreference)issuitableforadvancingintotheepiduralspace. Warnthepatientofthepossibilityofaparesthesiabeforethreadingthecatheter. Theliteraturestatesthatthreadingthecatheter35cmintotheepiduralspace reducestheincidenceofunilateralblock,intravascularcannulation,paresthesias, andcatheterknotting.Defertoyourstaffsjudgmentwhenthreadingthecatheter. Notethatitisimportanttodocumentboththedistancetotheepiduralspaceand wherethecatheteristapedtotheskin. Placethepatientinaslightlateraltiltduringepiduraldosing;thenursesarevery helpfulwithpositioning,andmostroomsareequippedwithhiprolls/pillows specificallyforthispurpose. Thecathetershouldbetestedwith3mLincrementsoflocalanestheticwith frequentnegativeaspirations(i.e.,drawbackthesyringebeforeeachinjectionto ensurethatthereisnobloodbackflow)andfrequentbloodpressurereadings.The traditionaltestdosewith1.5%lidocainewithepinephrinecanbesubstitutedby administeringyourchoiceoflocalanestheticsolution(seenextbullet) incrementallywithfrequentnegativeaspirations.

 Oncesubarachnoidandintravascularcatheterplacementhavebeenruledout,the fullloadingdoseshouldbeadministeredinslow,divideddoseswithfrequent negativeaspirations.Wecurrentlyhave2loadingdoseoptions:apremadesyringe with0.0625%bupivacainewith100mcgoffentanylcanbeadministered,followed bypatientcontrolledepiduralanesthesia(PCEA)pumpsettingsof12mL/hour, with4mLbolusevery10minutes(12/4/10).Alternatively,withdraw20mLofthe epiduralsolution(0.1%bupivacainesolutionwith2mcg/mL)fromthebagand administerindivideddoses,followedbyPCEAsettingsof8mL/hour,withbolusof 8mLevery15minutes(8/8/15). Evaluatethequalityandleveloftheblock,observingthepatientforroughly15 minutesandrecording3bloodpressurereadings. OurnewHospiraPCEApumpsareexcellentfordeliveringlaboranalgesiaandare fairlysimpletouse.Theyrequirespecialtubing,sobesuretograbthededicated tubingfromthestockroombeforeyouenterthepatientsroom;alternatively,extra tubingisstockedintheepiduralplacementcarts.Eachpumpisencasedinahard plasticcase/lockboxandhasakey(attachedviaarubberband)forsecuringour epiduralsolutions.Whenprogrammingthepump,firstplugitin(thenurses routinelyunplugthepumpsafterdeliveries).Next,presstheON/OFFbutton.The pumpperformsaselftestandasksthatyoupressENTER.Nextyouget3program options:press#3(CLEARPROGRAM,SHIFT,andHISTORY).IfitsaysKEYPAD LOCKED,pressOPTIONSandthenpress#3(FULLLOCK).Itthenasksyoutoenter thelocksequencenumber;tounlockthepumpsothatyoucanreprogramit,enter 13000.Thenresumeprogramming,electingCLEARPROGRAM,SHIFT,and HISTORY.ItwillsayCLEARINGPROGRAM.Nextitaskswhetheryouwant continuous,bolusonly,orcontinuous+bolus.Choose#3(CONT+BOLUS).Thenext pageasksyoutosettherateandpressENTERWHENDONE.Nextitasksyou whetheryouwanttoprogramaloadingdose.SayNO.Thenextpageasksforthe BOLUSdose;setitandpressENTER.ThefollowingpageasksforBOLUSLOCKOUT; enter10or15minutes,dependingonyourregimen,andpressENTER.Nextitasks foryourhourlylimit;select#4(NOLIMITSELECTED).Nextitasksyoutoenter CONTAINERSIZE;enter250mLifyouhaventremovedanysolutionfromthebag; enter230mLifyouhavewithdrawna20mLloadingdosefromthebag.Thenext pageisforAIRSENSITIVITY.Press2mL(option#2).Thentheresaprogramreview option,andyoumustpressthedownarrowtoreviewtheprogramparametersyou haveselected.Whenthereviewiscomplete,pressENTER.Theprogramwillbe savedandyoumustpressSTARTtobegintheinfusion. ProgramthePCEApumpateither12/4/10or8/8/15,dependingonwhichloading doseyouadministered,andexplaintothepatientthatsheshouldpressthepatient controlledanalgesiabuttonasoftenasshelikestogetalittleextramedicine. Explainthatthepumpisprogrammedandwillnotdelivertoomuchmedicineor permitanoverdose(thatis,itwilldeliverthebolusonlyevery10or15minutes,

dependingonyoursettings,regardlessofhowoftenshepressesthebutton). Emphasizetheimportanceofpressingthebuttonassoonasshefeelstheslightest discomfortinordertooptimizeherpainmanagement.Severalstudieshave demonstratedbroader,improvedspreadoftheepiduralsolutionswhenthepatient usesthePCEAbutton;fasterbolusesarethoughttobesuperiortoacontinuousslow infusionwithouttheintermittentboluses. Afteranepiduralhasbeenplaced,pleasewritethetimeofplacementontheboard nexttopatientsroomnumber(write,forexample,Epiat6:45am). COMBINEDSPINALEPIDURAL(CSE)PLACEMENT CSEsareidealformultiparousparturientswhopresentatanadvancedstageof dilation,aswellasforlaboringpatientswhopresentinpainearlyinlabor.Theyare alsoroutinelyperformedforC/S(withhigherdosesoflocalanestheticandopioids) whenthelengthofthesurgerymightoutlastthedurationofaspinal(e.g.,forrepeat C/Swithtuballigation,anextremelyobesepatientwhosesurgerymighttakealong time,etc.).Thatsaid,thedecisiontouseaparticularanalgesicoranesthetic techniqueshouldbeindividualized,basedonobstetricorfetalriskfactors,the preferencesofthepatient,andthejudgmentoftheanesthesiologist.Discuss whetheraCSEisappropriateforyourpatientwithstaff. ForalaboringCSE,wearehavingpharmacyprovidepremadesyringeswith1mL of0.25%bupivacaineand15mcgoffentanyl.Checkoutthepremadesyringefrom theanesthesiastockroomrefrigerator.Notethatthesesyringesarenotcurrently availableandthatseveralsolutionswithvaryingamountsoflocalanestheticand opioidaresuitableforaCSE;yourattendingstaffwillguideyouonthisfront. IdentifytheepiduralspacewithaTouhyneedleviathelossofresistance(LOR) technique.LORtoeitherairorsalineisappropriate;somepreferairtoensurethat dropletsuponduralpunctureareCSFandnotsalineseepingoutoftheepidural space. Passthe25GWhitacrespinalneedlethroughtheTouhyneedleuntilyou appreciateagiveorduralpop.Thenwithdrawthestylettefromthe25G Whitacreand,onceCSFisvisualized,attachasterile3mLsyringeinwhichyouhave drawnupyoursolutionof0.25%bupivacaineandfentanyl,andinjectwithoutprior aspiration.UsinganonLuerlok(i.e.,sliptip)3mLsyringemayfacilitateinjectionof theCSEsolution,asyoucanavoidhavingtotwistthesyringetothe25GWhitacre andtherebyreduceyourriskofdislodgingtheneedle.3mLnonLuerloksyringes arestockedintheepiduralcarts. OtherapproachestoaCSEtechniqueincludetheESPOCANcombinedspinal epiduralanesthesiaset,equippedwithan18GTouhyanda27Gspinalneedle,and theindividuallywrapped27GWhitacre,whichpasseswitheasethroughthe18G

TouhyintheBraunkit.Also,a25GWhitacrecanpassthroughan18GTouhy,but youmaydetectsomeresistance. Afterthespinalsolutionisadministered,thepatientsfeetshouldstarttofeel warmandcontractionsshouldbegintofeellesspainfulwithinafewminutes. Patientsmightbecomehypotensivefromtherapidandprofoundpainrelief associatedwithCSEplacement,sobereadytotreatwithephedrine.Also,fetal bradycardiaassociatedwiththeopioidintheCSEsolutionisnotuncommon,and mayalsobetreatedwithephedrine,fluids,oxygenbyfacemask,andbyplacingthe patientindifferentpositions(thenurseisveryhelpfulwiththesemaneuvers). OncetheCSEsolutionhasbeenadministered,withdrawthe25G(or27G)needle, whilekeepingtheTouhyneedleinplace,andquicklythreadtheepiduralcatheter. Donotdosetheepiduralcatheter.Rather,starttheepiduralinfusionattheroutine settings.Sufficientepiduralsolutionshouldaccumulateintheepiduralspacebythe timetheCSEsolutionwearsoff.Fromtimetotime,itishelpfultoaskthepatientto pressthePCEAbuttonwithin30minutesaftertheprocedureand,again,30minutes latertoensurethatenoughepiduralsolutionhasaccumulatedbeforetheCSEwears off. Warnthepatientthatshemightexpectpruritus,whichisusuallyselflimited. CESAREANDELIVERYWITHINSITUEPIDURAL WhenaC/Siscalledonapatientwithanepiduralinplace,firstconfirmthatthe epiduralisworking.Assessthequalityandleveloftheblockwiththewhiteplastic swordsthatarestockedinthetopdrawerofourepiduralcart.Feelthepatientslegs toassesswhethertheyarebothwarm(fromlocalanestheticinducedvasodilation). Askthepatientwhethershehasbeencomfortable,andaskhertorollslightlytothe sidewhileyouassesswhetherthecatheterisstillinplaceandstillatthesitewhere itwasoriginallytaped(refertothelaboranestheticrecordforthisinformation). WithdrawthefollowingmedicationsfromthePyxis:2vialsof2%lidocainewith epinephrine(alsoavailableintheepiduralcarts),fentanyl100mcg(50mcgpermL concentration),duramorph5mg(0.5mgpermLconcentration),midazalam2mg, three10unitvialsofoxytocin,ondansetron,andephedrine50mgand phenyephrine10mg(ifyounolongerhavethepressorsthatweredrawnduring epiduralplacementforthatpatient).Iftheresanyreasontosuspectuterineatony (forapatientwhohashadaprolongedinduction,apatientwithsuspectedfetal macrosomia,oramultiplegestationparturient,forexample),pullmethergine+/ hemabatefromtheiceboxinthestockroom.ThenursescanpullCytotec (Misoprostol)fromtheirPyxis(wedonothaveaccesstoit).Pleasebefamiliarwith dosingregimens,indicationsandcontraindicationsofeachofthesedrugs. Inpatientsroom,ensurethatReglan10mgIV,Bicitra30mLPO,andAncefhave beenadministeredandthatthepatienthasaworkingIVforfluidadministration.

NotethatsomeobstetriciansholdoffonadministrationofAncefuntilafterthebaby isdelivered;thenurseisawareofindividualobstetricianpreferences. Disconnectthepumpinfusionanddiscardtheremainingsolution.Then,fornon emergentcases,slowlydosethecatheterwith2%lidocainewithepiand bicarbonate(8.4%solution)inaratioof9mLoflidocaineto1mLofthe bicarbonate.ThebicarbonateservestoraisethepHofthelocalanestheticcloserto itspKaandhastenonset.Dependingonthepatientsblockpriortodosing,youmay needupto20mLofthelidocainewithepi/bicarbonatesolutiontoachieveaT4 block(blockatthenippleline).Givethissolutionin35mLincrementswith negativeaspirationbetweeneachdoseandwithfrequentbloodpressurereadings. NotethatpatientswhohavehadthehigherPCEAinfusionrateof12mL/hr,patients whohavehadadocumentedwettapwithan18Gor17Gneedle,andthosewhohave receivedaCSEmayrequiresignificantlyless2%lidocainewithepiandbicarb. Foremergentcases,testthecatheterintheusualfashion,rulingoutintravascular andintrathecalmigration,anddosewith20mLof3%2chloroprocainewith bicarbonate(2mLbicarbonateper20mLofchloroprocaine). Iftheepiduralblockisequivocal,itisprudentnottodosemorethan10mLsof2% lidocainewithepiandbicarb(asalways,individeddoses)priortoconsidering otheranestheticalternativessuchasaspinalfortheC/S.10mLof2%lidocaineis morethansufficienttoconfirmthatanepiduralisorisnotworking,asthepatient shouldgetaclearlevelanddensemotorblockwiththatamount.Ifmorethan10mL ofthe2%lidocaineisadministeredinanepiduralthatisequivocal,youriskahigh spinalifthedecisionismadetoabandonthatepiduralandconverttoaspinal. Havethepatientshusbandorsignificantotherwaitinthelaborsuite(ORclothes arestockedineachroom)oroutsidetheOR,whereORpants,shirt,hat,andmask areavailable,untilthepatientispreppedanddrapedandcheckedforanadequate anestheticlevel. IntheOR,placethepatientinleftuterinedisplacement(LUD)andadminister oxygenbynasalcanulaorfacemask. Administerfentanyl100mcgperepiduralonceithasbeenconfirmedthatthe epiduralqualityandlevelareadequate.WeroutinelyadministerDuramorph (preservativefreemorphine)atadoseof33.5mgperepiduralforpostoperative painrelief. Fromtimetotime,theepiduralblocksunexpectedlyprovidesinadequate anesthesia/analgesiaduringaC/S,andthepatientrequiresIVanalgesicadjuvants suchasketamine,fentanylor,occasionally,propofol,peryourstaffspreference.If youwithdrawketaminefromthePyxis,pleaseensurethatitisthe10mg/mL concentration,asanother,higherconcentrationisalsoavailable.Also,ensurethat

thepatientspainisnotduetofailuretoredosetheepiduralattheappropriate interval. Oncethebabyisdelivered,startyouroxytocininfusion.Premadebagsof20units pitocininD5LRareavailable.Alternativelyandmoreoften,weplace30unitsin500 mLofLR.Keeptheoxytocininfusionopeninitially;thenreassessuterinetone withinaminuteortwoandturndowninfusioniftoneisgood.Whenyoustartthe infusion,informthepatientthatshemightfeelflushedorlightheadedandthatshe mightdevelopaheadache.Pleasebefamiliarwithsideeffectsandadverseeffectsof oxytocin. Documentalldosesoflocalanestheticadministered,inboththelaborroomandin theOR,aswellasvitalsignsduringdosing.Documenttimeoffentanyland duramorphadministration,inadditiontoyourroutinecarefuldocumentationofall intraoperativeevents.Wecurrentlyrecordintraoperativeeventsonthelabor epiduraldocumentwhenwetransfertotheORratherthanchangetoaseparateOR record.IndicateontherecordthetransfertoOR,time,andindicationforC/S. Postoperativeordersaretobefilledoutforeachpatientwhoreceivesduramorph. Afteranoperativedelivery,youareresponsibleforsettinguptheORforthenext possibleemergency.Ensurethatcleanequipment,includingbreathingcircuit,nasal canula,ETTs,masks,EKGleads,pulseoximeter,bloodpressurecuffandcable,and suctionarereadilyavailable.Disposeofallusedsyringes,andwasteallunused narcotics. Accompanythepatientbacktotheroomanddocumentafinalsetofvitalsignsand theendtime. TOPPINGOFFLABOREPIDURALS Ifyougetcalledforinadequateanalgesiainapatientwithalaborepidural,askthe patientwhereexactlyshehurtsandwhetherherblockwasadequateearlierinthe courseofherlabor;checkthesensorydermatomelevelwiththewhiteplastic sword;evaluatewhetherthepatienthasamotorblock;feelwhetherbothlegsare equallywarm;checkthelaboranestheticrecordforpreviousdose,timeandresult oflasttopoffandforwhethertheepiduralwasadifficultplacement;andturnthe patientslightlytohersidetoassesswhetherthecatheterisstillinplaceandstillat theoriginalinsertionsite(seeanestheticrecordtoseewherecatheterwastapedat theskin). Checktheinfusionpump,tubing,andbagofbupivacainesolutiontoruleout malfunctions,leaks,oremptybags. Determinethepositionofthefetus,thestation,andthelatestcervicalexamfrom thenurse.Thismayinfluencethedrugyouchoosetoadminister.

 Severaltopoffregimensareappropriate,dependingonnatureofthepatients pain.Forexample,ifthepatienthasadensemotorblockbutalowdermatomal sensorylevel,youmightconsideradministeringarelativelylargevolumeofalow concentrationlocalanestheticsuchas1/8%bupivacaineor1%lidocaineorabolus fromthe0.1%bupivacaineepiduralpumpsolution.Alternatively,ifthepatienthas aweakorequivocalblockandisingreatdiscomfort,afewmLsof2%lidocaineor %bupivacaineisappropriate.Fentanyl100mcgperepiduraland/orafewmLsofa highconcentrationlocalanestheticsuchas%bupivacaineor2%lidocaineis oftenhelpfulwhendeliveryisimminentandthepatientiscomplainingofperineal pain.Similarly,ahighconcentrationlocalanestheticandfentanylperepiduralare usefulpriortovacuumorforcepsdeliveryandformanualextractionoftheplacenta andlacerationrepairs. Recordthesensorylevelbothbeforeandafteryourintervention,aswellasvital signs(includingfetalhearttones). BesurethatyouhaveephedrinereadilyavailableaswellasaworkingIVpriorto anytopoffs.Also,stayinconstantcommunicationwiththepatientduringtopoffsin ordertoevaluateCNSchangesthatmayresultfromanunanticipatedbolusoflocal anestheticintheintravascularorintrathecalspace.Beawarethatcatheterscan migrateintosubarachnoidandintravascularlocations;itisessentialalsoto administertopoffsindivideddoseswithfrequentnegativeaspirations. CATHETERPULLS Ifyouhavetheopportunity,itisgoodpracticetopulltheepiduralcatheter yourself,documentingthatthetipisintact.Ifresistanceismet,itisoftenhelpfulto askthepatienttoflexherbackorassumethepositionthatshewasinduring epiduralplacement. Afterthecatheterispulled,youcancloseoutthechart,documentingthedelivery time,Apgars,etc. EmptytheinfusionbaganddocumentwasteinmLsontheanestheticrecord. Ifapatienthasanycomplicationssuchasatony,concernforretainedproducts,or excessivebleedingduringdelivery,itisprudenttoleavethecatheterinsituuntil concernshavebeenresolvedandthenurseisreadytotransferthepatienttothe postpartumunit. SUBARACHNOIDBLOCKS WhenaspinalanestheticisindicatedforaCesareandelivery,ensurethatthe patienthasaworkingIVandhasreceivedReglan10mg,Bicitra30mLPO,and Ancef(unlesstheobstetricianpreferstoholdantibioticsuntilafterdelivery). ConsideranIVcrystalloidpreloadorcoload.AccordingtotheASAObstetric

Anesthesiaguidelines:Intravenousfluidpreloadingmaybeusedtoreducethe frequencyofmaternalhypotensionafterspinalanesthesiaforCesareandelivery; althoughfluidpreloadingreducesthefrequencyofmaternalhypotension,initiation ofspinalanesthesiashouldnotbedelayedtoadministerafixedvolumeof intravenousfluid.Thetimingofyourfluidadministrationiscontroversial;deferto yourstaff. EnsurethattheORisproperlyequippedwithsuction,abreathingcircuit,aface mask,nasalcannula,workinglaryngoscopeandblade,ETTsofvaryingsizes,emesis basin,emergencymedications,succinylcholine,aninductionagent,etc. Withdrawfentanyl,duramorph,versed,pitocin,ephedrineandphenylephrine (unlessabagwithphenylephrine100mcg/mLhasbeenpreparedalready)fromthe Pyxis,asinthecaseofanepiduralforC/S. Openandpreparethespinaltray(locatedintheneuraxialblockcartineachOR) equippedwitha25Gpencilpointneedle.Notethatwehavemorethanonespinal tray,soreviewtheboxcontentsbeforeopening. Inasterilefashion,drawup1.42.0mLs(dependingonpatientsheight,weight, andnumberofpriorCesareandeliveries,aswellasonyourstaffspreference;we oftenuse1.6mLs)ofthe0.75%bupivacaineintothesterilesyringe.Usethefilter strawthatisprovidedinthekitstodrawupyourlocalanesthetic,asglassparticles fromtheglassbupivacainevialcanotherwisecontaminateyouranestheticsolution. Haveanassistantdrawupfentanyl(1020mcg,dependingonyourstaffs preference)andduramorph(100200mcg,dependingonstaffsclinicaljudgment) inaTBsyringeandinsertitintoyourbupivacainesolution.Alternatively,dropaTB syringeontoyoursterilefieldandwithdrawtheappropriateamountofeachopioid whileanassistantholdsthevialsforyou.Pushairbubblesoutyourspinalmixprior tostartingtheprocedure. Occasionallywealsoaddepinephrinetoourlocalanesthetic/opioidmixfor subarachnoidblocksinordertoprolongtheeffectand,possibly,forenhanced analgesia.Theepinephrineisavailableinthekits,andyoucandoanepiwash beforedrawingupyour0.75%bupivacainebyshoweringtheinsideofyoursyringe withepi.Alternatively,consideradding100200mcgofepinephrinetoyourlocal anesthetic/opioidsolution.Notethatsomepractitionersprefertoavoidepinephrine inthesettingofpreeclampsiaorhypertension.Also,pleasebecarefultodistinguish betweentheepinephrineandbupivacaineglassvials,bothofwhicharesuppliedin thekits.Whendrawingupyourmedications,lookatthevial,readtheexpiration dateandconcentrationofthebupivacaine,andkeepthesmallerepinephrineglass vialasafedistanceawayinordertominimizemedicationerrors. Thepatientmaybeseatedorinthelateralpositionduringplacementofa subarachnoidblock.Allmonitorsshouldbeinplaceandyourpressorsshouldbe immediatelyavailable(somemayprefertopretreatwithIVorIMephedrine). Afterthe25Gpencilpointneedleisadvancedthroughtheintroduceruntiladural popisdetected,withdrawthestyletteandwatchforCSFbackflow.Attachthe syringewiththespinalsolutioncarefullytothe25Gandholdsteadilyinplace;itis helpfultovisualizeasmallwhirlofCSFinthesyringepriortoinjectingthesolution

bygentlywithdrawingthesyringe.Warnthepatientthatherlegswillstartfeeling heavyandwarmasthesolutionisadministeredintotheintrathecalspace. Afteradministeringthesolution,havethepatientimmediatelyliedown(ifshehad beenseated)orrolloveronherback(ifshehadbeeninthelateralposition)and placethepatientinleftuterinedisplacement.Administeroxygenbynasalcannula orfacemask,takefrequentbloodpressurereadings,andmaintainconstant communicationwiththepatientforseveralminutesasthespinalsetsup.Askthat thepatientalertyouifshebeginstofeelnauseated,lightheaded,confusedordizzy, astheseareearlysignsofhypotensionorahighblock.Bepreparedtotreatwith ephedrineorphenylephrineandIVhydration.BefamiliarwiththeORsetup, particularlywithwhereemergencyequipmentanddrugsarelocated. Ifpatientsgetanxiousandfeelthattheycannotbreathe,forexample,reassurance andcontinuouscommunicationisoftenhelpful,asishavingthesignificantother joinyouintheOR.Versedin12mgIValsohelpsalleviatetheanxiety,although somepractitionersprefertoholdoffuntilafterdelivery. Assessthelevelofyourblockwiththewhiteplasticswords.Askthepatientto squeezeyourhandsisaneffectivewaytoruleoutahighblock,asislisteningfora strong,unchangedvoice. Alternativespinalkitsandneedlesareavailablefordifficultcases,suchassuper morbidlyobeseparturients.Pleasedefertoyourstaff. ForrepeatCesareandeliveries(athirdorfourthC/S),patientswhoaresuper morbidlyobese,patientswhohavehadmultipleabdominalproceduresandhave suspectedadhesions,patientswhodesiretuballigationafterCesareandelivery, patientswithprevias,accretas,orotheruterinepathology,etc.acombinedspinal epiduralmayproveanappropriateanesthetictechnique.TheCSEforasurgical procedureisperformedinthesamemannerasaCSEforlaboringpatients,butthe 0.75%bupivaine/opioidsolutiondescribedinthissection(+/epinephrine)is administeredinlieuofthelighterlocalanestheticsolutionusedduringlabor.When performingaCSEforsurgicalprocedures,threadthecatheterquicklyafter administrationoftheanestheticsolutionandplacepatientsupinewithLUDas swiftlyaspossible. COMPLICATIONSOFNEURAXIALBLOCKS Hypotension: Hypotensionisacommonsideeffectofadministrationoflocalanestheticinthe epiduralorsubarachnoidspace. ConfirmLUD,evaluatethepatientforsymptoms(n/v,dizziness,lightheadedness, etc.),andassessthefetalhearttracings. OpentheIVfluidsandadministerephedrineifthepatientissymptomatic,thefetus isindistress,orifthereisagreaterthan20%dropinSBP.Consideroxygenbymask orpositionalmaneuvers.Gethelp,ifnecessary. Checkthepatientsanestheticlevelandruleoutinadvertentspinal,accidental excesslocalanestheticdose,etc.

WetTap: Remaincalmandreassurepatient.Immediatelytakeacourseofaction:either threadthecatheterintrathecallyorremovetheTuohyneedleandattemptepidural placementatanotherlevel. Ifyouopttothreadtheepiduralcatheterintotheintrathecalspace,25cm (maximum)shouldsuffice.ConfirmbackflowofCSF,anddosetheintrathecal catheterforalaboringpatientperyourstaffspreference.Youmightstartwith1mL of0.25%bupivacainewithfentanyl15mcg(aswedowithCSEsforlaboring patients),followedbyacontinuousinfusionof1mLof0.1%bupivacainewith2 mcg/mLoffentanylperhour.Adjustyoudoseasnecessary,butbesuretooptfor continuousinfusiononthepumpsettingsandtodisablethepatientcontrolled dosingoption.TellthepatientthathercatheterisintheCSFspaceandthatshe mightbeatriskofaheadache,explainingthatwettapwithheadacheisanot unusualcomplicationofepiduralplacement.Labelthecatheterasintrathecal, advisethenurseandallstaff,andwriteintrathecalcatheterontheboardnextto thepatientsname. IfyouopttoremovetheTouhyandattemptepiduralplacementatanotherlevel, advisethepatientthatshemightdevelopaheadache.Also,beawarethatdosingthe epiduralinthesettingofapriorfrankwettapmightrequiredosingadjustments. Dosetheepiduralprudentlyandwithfrequentassessementsandbloodpressure measurements;reassessthepatientfrequentlyduringthecourseofherlabor. Documentthatthepatienthadawettaponboththelaborrecordandinour logbookinthestockroom.Also,passonthewordtostaffandteammemberswho takeoverafteryou.Followuponthesepatientsfor35dayspostpartum,assessing foranysignsofpostduralpunctureheadache(PDPH). Onoccasionittakesmultipleattemptstolocatetheepiduralspace,placingthe patientatriskforaduraltearevenintheabsenceofafrankwettap.Pleaseinform thepatientandteammemberswhoassumecareonceyourshiftisoverthatthe patientmaybeatriskforaheadache.Communicationisessentialinthisscenario,as otherwisethepatientmaygountreatedforaPDPH. PDPH: Whetherthepatientisinthehospitalorathome,obtainandreviewthechart. Evaluateneedlesize,difficultyofplacement,numberofattempts,andwhetherthere wasafrankwettap.Thenursingsupervisorisavailable24hours/dayinthe hospitalandcanobtaintheanestheticrecordfromMedicalRecordsatanyhour. Evaluatethenatureoftheheadache.Whendiditstart?Isitpositional?Wheredoes ithurt?Isittotallyrelievedwhenlyingdown?Doespatienthavetinnitus,visual changesornuchalrigidity?Doessherecallwhethertheepiduralplacementwas difficultorwasshewarnedthatshemightdevelopaheadache?Doesshehavea historyofheadaches,andisthisheadachesimilartoherusualheadache?Hasshe resumedhernormalcaffeineintakeandhasshebeeneating?Doesshehavea historyofhighbloodpressure,washerpregnancycomplicatedbyhighblood pressureorpreeclampsia,andwhatisherbloodpressurecurrently?Isshefebrile?

Examinethespinal/epiduralinjectionsiteandassesspatientsmotorstrength. Assessalsothepatientshydrationstatus. ConservativemanagementforaPDPHisagoodoptionfor24hours.Considerbed rest,withtheheadofthebedflat;hydration;scheduledmotrinorfioricet; antiemetics,ifnecessary;havethepatientresumehercaffeineintakeandavoid alcohol;explaintheprobableetiologyoftheheadacheandtheepiduralbloodpatch treatmentoption. Abloodpatchcanbeconsideredifthepatientdeclinesconservativetreatment,is tobedischargedthatday,hasdocumentedevidenceofafrankwettap,orfails conservativetreatment.Explainalltherisksandbenefitsofanepiduralbloodpatch andhavepatientsignaconsentformpriortotheprocedure.Ananestheticrecord shouldbefilledoutforabloodpatch.Afelloworstaffmemberwilleitherperform thebloodpatchorassistyou. Afterabloodpatch,instructthepatienttoavoidstraining,rapidbending,bearing down,orliftingheavyobjectsforseveraldays.Alsoaskhertorefrainfromalcohol intake.Shecancontinuetakingmotrinorfioricet(taperthelatterintheusual fashion). RequestthatthepatientreturntotheERorforananesthesiaconsultifthe headacherecurs,afeverorstiffneckdevelops,shedevelopsnumbnessorweakness inherlowerextremitiesorbowel/bladderdysfunction,ifincreasedrednessor tendernessdevelopsattheinjectionsite,orifshehasanyquestionsorconcerns aboutheranestheticcare. Advisethepatientthatinasmallpercentageofthecases,asecondepiduralblood patchmayberequired.Giveherstatisticsregardingthesuccessrateofafirstblood patch,thesuccessrateofasecond,thetimeframeforresolutionoftheheadacheifit recurs,etc. Recordthatabloodpatchwasperformedonthatpatientintheloginthestock room. AsymmeticSensoryBlock: Aunilateralblockisacommoncomplicationofepiduralprocedures.Itisoften associatedwithacatheterbeingthreaded(ormigrating)toodeepintotheepidural space(literaturesuggeststhatthreadingtheepiduralcatheter35cmisoptimal)or withhavingthepatientlieononesidefortoolong. Totroubleshoot,rollthepatientonhersideandensurethatthecatheterisatthe properdepthattheskin;ifithasmigratedinward,pullitbacktothesitewhereit wasoriginallytapedatskinand,afterrepositioningthepatientonthesidewithout theblock,eithergiveamanualbolusofalocalanestheticsolutionoraskthatthe patientpressherPCEAbutton.Ifthecatheterisstillwhereitwasoriginallytaped, rollthepatientonthesidethathasdiminishedanalgesia,withdrawthecatheter12 cmandbolusasabove.Remembertoaspiratepriortoadministeringanybolus. PatchyBlock: Assesswherethepatientisfeelingdiscomfort.Doesshehaveawindowofpain? Issheexperiencingperinealpainimmediatelypriortodelivery?

Ruleoutasubduralblock;todothis,youmustbefamiliarwiththemanifestations ofasubduralblock.Ifyoufeelcertainthatthepatientisexperiencingasubdural block,considerimmediatelyreplacingthecatheter. Ifthepatientisexperiencingperinealpain,considerfentanyl100mcgperepidural orafewmLsofadenselocalanestheticsolution,asdescribedinthetroubleshooting section. Iftheepiduralisworkingproperlyandthepatienthasawindowofpain,consider abolusofadenselocalanestheticsolutionwiththepatientlyingwiththeunblocked segmentdown.Havealowthresholdforreplacingthesecatheters,asitisoften difficulttoremedyawindow. FetalBradycardia: Ensurethatthenurseispresentandhasplacedthepatientonhersidetoavoid compressionofthebloodvessels. Consideroxygenbymask. Evaluatethepatientforsymptomsofhypotension;takeabloodpressurereading. Ifthepatientissymptomaticorhypotensive,opentheIVfluidsandadminister ephedrine.Administeringephedrineisoftenhelpfulalsointheabsenceofovert hypotension. Notifyyourteamifthebradycardiacontinuesandifthereisconcernforimminent C/S. Have20mLof3%2chloroprocainewith2mLofbicarbonatedrawnupfor immediatedosingoftheepiduralifproceedingtotheORemergentlyisimminent. IntravascularInjection: Whentestingacatheter,rememberthateverydoseisconsideredatestdose.Use 3mLincrementsoflocalanestheticwithfrequentnegativeaspirationsandfrequent bloodpressurereadings. Toassessforintravascularinjections,askifthepatienthasringingintheears, dizziness,circumoralnumbnessorametallictasteonthetongue,restlessness,or suddenonsetanxiety.Watchfortachycardia(ifanepinephrinecontaininglocal anestheticwasused)andforseizure(ifalargeamountofhighconcentrationlocal anestheticwasdosedatonce).Also,takeasmallsyringeanddrawbackforblood whenevaluatingasuspiciousscenario.Holdthesyringebelowthelevelofthe patientasyougentlyandprotractedlydrawback. Ofnote,rememberthatweroutinelyadminister100mgoflidocaineintravenously intheORwithoutnotinganyofthesesignsandsymptomsdescribedabove;several mLsofthelocalanestheticsolutionmaybenecessaryforthepatienttodetectany sensorychanges.Also,bereassuredthatweuselowconcentrationsoflocal anestheticinsmall,incrementaldoseswithfrequentaspirationsinorderto minimizecomplicationsofintravascularinjections.Lastly,thesoft,wirereinforced cathetersincommonusetodayhavealowerincidenceofintravascularcannulation. Intheeventofaknownintravascularinjectionofdosesgreaterthanatestdoseor ifthepatientissymptomatic,stopinjecting,gethelpSTAT,preparefor administeringoxygenandprotecting/supportingtheairway,andprepare

emergencydrugs,includinglipid.HavealowthresholdfortransfertotheOR,ifthe problempersists. OBSTETRICANESTHESIACURRICULUM:LEVEL1 Note:Forspecificsonfulfillingthe6corecompetencyrequirements,pleaserefertothe ObstetricAnesthesiaguidelinespostedontheTulanedepartmentalWebsite.The followingprovidesanabbreviatedversionofexpectationsforyourmanualskills developmentandyourcoreknowledgeacquisitionoverthecourseofyourrotationsin ObstetricAnesthesia.ThecurriculabelowaremodifiedfromtheSocietyforObstetric AnesthesiaandPerinatology(SOAP),andarenotintendedtobeexhaustive. ManualSkillsDevelopment: Residentsareexpectedtolearnanddevelopproficiencyinthefollowingskills duringroutinecases:1)epiduralcatheterplacementwithasuccessrateof70%by theendofthemonth;minimalnumberofwettaps2)subarachnoidblockplacement withasuccessrateof7080% CoreKnowledgeAcquisition: A) Maternalphysiologypriortolaboranddelivery a. Cardiovascularsystem:cardiacoutput,strokevolume,heartrate, systemicvascularresistance,bloodpressure,andbloodvolume b. Describetheeffectsofsupinepositiononbloodpressureanduterine bloodflow c. Pulmonary,respiratoryandairway:functionalresidualcapacity,tidal volume,respiratoryrate,minuteventilation,alveolarventilation, workofbreathing,airwayresistance,chestwallcompliance,arterial bloodgases,ventilation/perfusionmatching,andMallampati(both overthecourseofpregnancyandduringlabor) d. Gastrointestinal:gastricmotility,gastricemptying,loweresophageal sphinctertone,gastricpH,riskofaspirationpneumonitis e. Hematologic:hematocrit,bloodvolume,platelets,whitebloodcells, coagulationfactors,fibrinogen f. Renal:BUN,Cr,glomerularfiltrationrate,renalbloodflow g. Endocrineandmetabolism:progesterone,estrogen,prolactin, aldosterone,angiotensin,rennin,cortisol,prostacyclin,thromboxane, insulinandglucose,etc. h. Musculoskeletal:backpain,sciatica,carpeltunnelsyndrome,lordosis i. Centralnervoussystem:paintolerance,anestheticrequirementsfor bothgeneralandregionalanesthesia B) Fetalandplacentalphysiology a. Embryogenesis b. Placentaldevelopmentandstructure c. Placentalgasexchange,nutrienttransport,drugtransfer d. Fetalcirculation

C)

D)

E)

F)

G)

H)

e. Fetalevaluation:Intrauterinegrowthrestriction(IUGR),nonstress test(NST),biophysicalprofile(BPP),fetalheartrate(FHR),fetalblood gasvalues,etc. Neonatalphysiology a. APGAR b. Physiologicadaptationstoextrauterinelife,includingcirculatoryand respiratorychanges c. Resuscitationofthenewborn:whatistheroleoftheanesthesiologist? Localanesthetics a. GeneralprinciplesofLApharmacology b. CriteriaforselectingspecificLAs c. Describeeffectsonmaternalcirculation,uterinetone,uterineblood flow,andFHR d. Effectofvasoconstrictors e. Effectofsodiumbicarbonateononsetandduration f. Signsandsymptomsofsystemictoxicity g. Neurotoxiceffects Agentsaffectinguterinetone a. Agentsthataffectuterinetone:volatileagents,ketamine, nitroglycerine b. Tocolytics:Ethanol,Mg,calciumchannelblockers,etc. c. Uterotonics:Pitocin,Cytotec,Methergine,Hemabate. Opioids: a. Opioidagonistsforneuraxialblockade b. Treatmentofopioidsideeffects c. Mixedagonistantagonists d. Effectsonthefetus Druginteractions a. Whataretheeffectsofvasoactiveagentsontheonset,intensity,and durationofsensoryandmotoreffectsofLAs? b. Whataretheeffectsofopioidsontheonset,intensity,anddurationof sensoryandmotoreffectsofLAs? c. Whatistheeffectofsodiumbicarbonateontheonset,intensity,and durationofLAs? d. Howdoesmagnesiumaffectneuromuscularblockingdrugs? Managementoflabor a. Describethefirst(activeandlatentphases),secondandthirdstages oflabor b. Describetheeffectsofuterinecontractionsonplacentalexchangeand fetaloxygenation c. Describetheanatomyoftheepiduralspace d. Whataretheclinicalmanifestationsofuterinehypertonusand hyperstimulation e. Doesepiduralanalgesiaaffectlabor? f. Howdoeslaboraffectmaternalhydration,ventilation,and hemodynamics?

I) Regionalanesthetictechniquesfortheobstetricpatient a. Describetechniquesavailableforroutinelaborandvaginaldelivery, vacuumorforcepsdelivery,manualextractionoftheplacenta,uterine inversion,nonurgentandemergentCesareandelivery,dilationand curettage(D&C),tuballigation,andcervicalcerclage b. Describeneurologicpathwaysthatconveypainduringthefirstand secondstagesoflabor c. Listallregionalanesthetictechniquesthatcanproduceeffective analgesiainthefirstandsecondstagesoflabor d. Listabsoluteandrelativecontraindicationsofregionalanesthesia e. Describethehemodynamiceffectsofepiduralsandsubarachnoid blocks f. Listcomplicationsofregionalanesthesia,includingPDPH,backache, nervepalsy,meningitis,abscess,andhematoma J) Generalanestheticsforobstetrics a. Whataresomeoftheconcernsaboutadministeringgeneral anesthesiatoaparturient,bothearlyinpregnancyandatterm? b. Listindicationsforgeneralendotrachealanesthesia c. Whataretheventilatoryrequirementsforparturients? d. Describehowdrugsusedintheinductionandmaintenanceofgeneral anesthesiaaffectuterinetone,fetalperfusion,andtheneonate e. Describethestepsofthedifficultairwayalgorithm K) Resuscitation a. Describeclinicalfactors(bothmaternalandfetal)thatarepredictive ofaneedforneonatalresuscitation b. Describeidealmanagementofmaternalresuscitation L) Complicationsofanesthesiaduringpregnancy a. Aspirationpneumonitis b. Failedintubation c. Complicationsduringemergence d. PDPH e. Commonneurologiccomplications M) Anestheticmanagementofnonobstetricsurgeryduringpregnancy a. Describeadvantagesanddisadvantagesofperformingelective operationsduringthefirst,secondandthirdtrimestersofpregnancy b. Whenisfetalheartmonitoring(FHM)indicated? c. Doouranestheticagentsaffectthefetus?Whichones?How? d. Discusstheeffectsofmaternalhypotension,hyperventilation, hypoventilation,andbloodtransfusiononfetalwellbeing N) EthicalIssues a. Discussthepotentialformaternalfetalconflictsofinterest b. Discussthecurrentgestationalageweightlimitsforfetalviability c. Discussinformedconsentissues d. Demonstrateanunderstandingofdivergentreligiouspointsofview O) Crisisaversion

a. Causesandmanagementoffetaldistress:umbilicalcordprolapse, uterinerupture,vasaprevia,uterinerupture,hemorrhage b. Causesandmanagementofvaginalbleeding:placentaprevia, abruptioplacenta,uterinerupture,uterineatony,retainedproductsof conception c. Causesandmanagementofhypertensioninpregnancy:chronicHTN, gestationalHTN,preeclampsia,eclampsia d. Causesandmanagementofcoagulopathyinpregnancy:HELLP, abruption e. Diagnosticcriteriaandanestheticmanagementofpreeclampsiaand eclampsia:BPcontrol,seizureprophylaxis,druginteractions OBSTETRICANESTHESIACURRICULUM:LEVEL2 Manualskillsdevelopment: Thegoalatthislevelistomasterskills,withemphasisonefficiency.Bytheendof themonthyouareexpectedto:1)placeepiduralsinlessthan10minutes,witha lowreplacementrate,lowwettap/PDPHrate,andhigh(80%)successrate2)place subarachnoidblocksin5minutes,witha90%successrate Anestheticandobstetricmanagementofhighriskpregnancy: Foreachofthefollowingdiseaseprocesses,bepreparedto:listcommonobstetric concernsandmanagementstrategies;describetheanestheticimplications,focusing onmaternalandfetalconsiderations;assesstheseverityofthediseaseand determinewhenapatientsconditionwarrantsICUorhighriskunitcare;describe theanestheticmanagementoptionsforvaginalandCesareandelivery A) Hypertensivedisordersofpregnancy a. ChronicHTN b. Preeclampsia/eclampsia:diagnosticcriteria,epidemiology, pathophysiology,HELLPsyndrome,andmedical/obstetric management(withemphasisontermvs.pretermfetus,mildvs. severedisease,seizureprophylaxisandMgeffects,antihypertensive medicationoptions,managementofoliguria,andindicationsfor invasivemonitoring) B) Multiplegestation: a. Listandcomparerisksassociatedwithmultiplegestations b. Distinguishtheseriskswithtwinsvs.tripletsvs.quadruplets C) Pretermlabor:discussrisks(fetalandmaternal)associatedwithpreterm laborandtocolytictherapy D) Abnormalfetalpresentations E) Antepartumandpostpartumhemorrhage F) Maternalandfetalinfection G) Endocrinedisease

H)

I) J)

K)

L)

M)

N) O) P) Q) R)

a. Diabetes,withemphasisonthecriteriafordiagnosis,indicationsfor therapy,effectofpregnancyonthediseaseprocess,fetaleffectsofthe disease,andtheeffectsoftreatmentonbothmotherandfetus b. Thyroiddisease,withemphasisondiagnosisandtreatmentofboth hypothyroidismandhyperthyroidism Substanceabuse a. Identifyrisksandcomplications b. Recommendpostoperativepaincontrolstrategies c. Developaplanforcomplicationsofwithdrawal Immunologicdisease Neurologicdisorders a. Multiplesclerosis b. Spinalcordinjury c. Myastheniagravis d. Seizuredisorders Respiratorydisease a. Asthma,includingthepathophysiology,theeffectsofpregnancyon asthma,andasthmaseffectsonpregnancy b. ARDS Cardiovasculardisease a. Congenitalheartdisease b. Ischemicheartdisease c. Valvularheartdisease d. Peripartumcardiomyopathy Hematologicandthromboembolicdisease a. Anemias b. Thalassemias c. Sicklecelldisease d. Thrombocytopenias e. Plateletandbleedingdisorders f. Anticoagulationmedications MorbidObesity MalignantHyperthermia Renaldisease Liverdisease Musculoskeletaldisorders a. Scoliosis b. Rheumatoidarthritis c. Spinabifida d. Priorbacksurgery

OBSTETRICANESTHESIACURRICULM:LEVEL3 A) Actindependentlyasaconsultant,formulatingananestheticplanforhigh riskparturients

B) Developcriticalevaluationskills C) Developmanagementandleadershipskills a. Demonstrateindependence b. Developcommunicationsskills c. Demonstrateleadership d. Supervisejuniorresidents e. Teachjuniorresidentsandparticipateinmanagementtasks f. Introductiontoclinicalresearch g. Bedsideteaching