"Why did that just happen?"
After spinal anesthesia for cesarean delivery, the patient becomes nauseated and hypotensive. This occurs primarily because of:
What is sympathetic blockade causing decreased venous return?
Key Point: Loss of sympathetic tone → vasodilation.
Clinical Takeaway: Nausea is often the first sign of hypotension.
During cardiac arrest in a pregnant patient, this maneuver should be performed immediately to improve venous return during CPR.
What is left uterine displacement?
Key Point: Aortocaval compression impairs preload and cardiac output.
Clinical Takeaway: Manual LUD — not just a wedge — during CPR.
“Give Methergine!” — The standard dose of methylergonovine for uterine atony is:
What is 0.2 mg IM?
Key Point: IM administration limits rapid hypertensive effects.
Clinical Takeaway: Never give Methergine IV and avoid in hypertensive patients.
During induction of general anesthesia for a stat cesarean delivery, end-tidal CO₂ is absent, oxygen saturation is falling, and the stomach is distending. The MOST appropriate immediate action is:
What is remove the endotracheal tube and ventilate with 100% oxygen?
Key Point: Esophageal intubation must be assumed when ETCO₂ is absent.
Clinical Takeaway: Do not persist with a misplaced tube — oxygenation comes first.
During labor epidural placement, you obtain clear fluid through the Tuohy needle consistent with a wet tap. The MOST appropriate immediate management is:
What is thread the catheter intrathecally or remove the needle and re-site the epidural at another level?
Key Point: Unintentional dural puncture increases the risk of post–dural puncture headache.
Clinical Takeaway: Recognize the wet tap immediately and make a deliberate plan — don’t pretend it didn’t happen.
A labor epidural that worked well suddenly fails during advanced labor. The most likely explanation is:
What is catheter migration or differential block due to labor progression?
Key Point: Anatomy and patient movement change over time.
Clinical Takeaway: A working epidural can still fail later.
Aside from uterine displacement, ACLS medications and defibrillation in pregnancy should be:
What is the same as in nonpregnant patients?
Key Point: Standard ACLS algorithms apply.
Clinical Takeaway: Do not delay or alter life-saving drugs due to pregnancy.
"Push Hemabate!” — The standard dose and route of carboprost is:
What is 250 micrograms IM?
Key Point: Carboprost is a prostaglandin F₂α analog.
Clinical Takeaway: Always confirm no history of asthma before giving.
During general anesthesia for cesarean delivery, a common technique is to deliver a 50/50 mixture of sevoflurane and nitrous oxide to achieve approximately 1 MAC of anesthesia. Compared with increasing volatile anesthetic alone, the addition of nitrous oxide helps preserve
What is uterine tone?
Key Point: Nitrous oxide provides MAC-sparing without significant uterine relaxation.
Clinical Takeaway: Using nitrous oxide allows lower volatile concentrations, reducing the risk of uterine atony while maintaining adequate anesthesia.
You accidentally push 20 mL of epidural local anesthetic IV for a stat cesarean section. She’s probably going to be okay because the drug is:
What is Chloroprocaine
Key Point: Chloroprocaine is rapidly metabolized by plasma esterases.
Clinical Takeaway: Fast onset, short duration, and rapid metabolism make chloroprocaine relatively forgiving compared with amide local anesthetics.
Barash says: Chloroprocaine is rapidly hydrolyzed by plasma esterases, limiting systemic toxicity even after inadvertent intravascular injection.
Neck stiffness, photophobia, and nausea in PDPH occur primarily because of:
What is meningeal traction from low CSF pressure?
Key Point: Symptoms can mimic meningitis but are pressure-related.
Clinical Takeaway: Fever or altered mental status should prompt alternative diagnoses.
If maternal cardiac arrest persists, perimortem cesarean delivery should ideally begin within this time frame.
What is 4–5 minutes?
Key Point: Improves maternal venous return and fetal outcome.
Clinical Takeaway: This is a maternal resuscitation procedure first.
Barash says: Perimortem cesarean delivery should be initiated within approximately 4–5 minutes of maternal cardiac arrest if resuscitation is unsuccessful. (Clinical Anesthesia, 8th ed., Ch. 41)
“Can we repeat that?” — Carboprost doses may be repeated at what interval?
What is every 15–90 minutes?
Key Point: Effects are short-lived; repeat dosing is common.
Clinical Takeaway: Track cumulative dose carefully
A standard epidural test dose of 3 mL of 1.5% lidocaine with epinephrine 1:200,000 contains approximately how much lidocaine?
What is 45mg
1.5% Lidocaine = (15mg/mL)
In the scenario above, lidocaine would be more dangerous primarily because it:
What is an amide local anesthetic with slower hepatic metabolism?
Key Point: Amide local anesthetics persist longer in circulation.
Clinical Takeaway: Drug choice matters when time pressure increases error risk.
After placement of an apparently functioning labor epidural, a previously comfortable patient suddenly develops unilateral Horner syndrome (ptosis, miosis, facial anhidrosis). Why did that just happen?
Subdural spread of local anesthetic
Key Point: Subdural spread produces patchy, unpredictable, and often high sensory blockade.
Clinical Takeaway: Horner syndrome after epidural = think subdural spread, not LAST
During CPR in a pregnant patient, endotracheal intubation may be more difficult primarily because of:
What is airway edema and increased aspiration risk?
Key Point: Pregnancy alters airway anatomy and physiology.
Clinical Takeaway: Assign the most experienced airway provider early
“Give miso!” — A commonly used dose of misoprostol for postpartum hemorrhage is:
What is 800–1000 micrograms rectally?
Key Point: Misoprostol is a prostaglandin E₁ analog.
Clinical Takeaway: Useful when other uterotonics are contraindicated or unavailable.
A standard epidural test dose of 3 mL of 1.5% lidocaine with epinephrine 1:200,000 contains approximately how much epinephrine?:
What is 15 micrograms of epinephrine?
During spinal needle placement, the patient reports a sudden, sharp, electric shock–like pain radiating down one leg. What is the MOST appropriate immediate action?
What is withdraw and redirect the needle before injecting?
Key Point: Paresthesia suggests nerve root contact.
Clinical Takeaway: Never inject local anesthetic when the patient reports pain or paresthesia.
Following combined spinal–epidural labor analgesia, the fetus develops transient bradycardia despite maternal stability. This is most likely due to:
What is rapid decrease in maternal catecholamines causing uterine hypertonus?
Key Point: Sudden pain relief alters uterine tone.
Clinical Takeaway: Usually self-limited but must be anticipated.
A laboring preeclamptic patient develops hypotension and a widened QRS on EKG. This indicates:
What is worsening magnesium toxicity affecting myocardial conduction?
Key Point: High magnesium levels depress myocardial excitability.
Clinical Takeaway: Cardiac effects signal advanced toxicity.
“She’s still hypotensive and bleeding.” A preeclamptic patient receiving massive transfusion has worsening hypotension and poor uterine tone despite vasopressors and uterotonics
What is calcium?
Key Point: Massive transfusion causes citrate-induced hypocalcemia; magnesium further depresses myocardial contractility and vascular tone.
Clinical Takeaway: In bleeding preeclamptic patients on magnesium, hypocalcemia is common and calcium replacement can rapidly improve blood pressure and uterine tone.
Barash says: Massive transfusion may cause hypocalcemia due to citrate toxicity, which can impair myocardial contractility and vascular tone; calcium replacement should be administered as indicated. (Clinical Anesthesia, 8th ed., Ch. 41)
The intercristal (Tuffier’s) line drawn between the iliac crests most commonly corresponds to which vertebral level in adults? AND
In adults, the conus medullaris most commonly terminates at approximately which vertebral level?
What is L4 (or the L4–L5 interspace)?
What is L1–L2?
A laboring patient with an epidural catheter becomes rapidly hypotensive, dyspneic, and develops a dense bilateral motor block shortly after a bolus intended for labor analgesia. What should you do NEXT?
What is secure the airway and provide ventilatory support while treating hypotension?
Key Point: This presentation is most consistent with an unrecognized intrathecal bolus causing a high spinal.
Clinical Takeaway: High spinal = airway emergency first, not just hypotension.