Uterine blood flow is decreased in most parturients when supine due to aortocaval compression.

Uterine blood flow can be increased in about 15% of parturients when supine due to the uterine arteries taking off above the level of compression of the aorta.

Uterine blood flow decreases when maternal systolic blood pressure drops below $$80$$ mm Hg.

Effective epidural analgesia can increase uterine blood flow in the parturient with severe preeclampsia by up to $$80\%$$ .

Maternal hypocapnia from hyperventilation causes uterine artery vasoconstriction, resulting in decreased blood flow.

Methylergonovine, $$200$$ micrograms IM: Severe preeclampsia

Carboprost (15-methyl-PGF2α), $$250$$ micrograms IM: History of severe asthma

Oxytocin, $$10$$ units IV: Uncorrected maternal hypovolemia

Misoprostol, $$1{,}000$$ micrograms: Maternal fever

All of the above are appropriate contraindications.

Etomidate $$0.2$$ mg/kg, succinylcholine $$1.5$$ mg/kg, both IV

Propofol $$2$$ to $$3$$ mg/kg, succinylcholine $$1.5$$ mg/kg, both IV

Spinal injection of bupivacaine, $$12$$ mg, and fentanyl, $$25$$ mcg

Spinal injection of bupivacaine, $$12$$ mg, without fentanyl

Inhalational mask induction with preserved spontaneous ventilation until anesthetized to avoid endotracheal intubation in a trauma patient

Maternal supraventricular tachycardia

Maternal hyperglycemia

Maternal pulmonary edema

Maternal hyperkalemia

Fetal tachycardia

Ordering an echocardiogram to rule out peripartum cardiomyopathy

Furosemide, $$40$$ mg IV

Evaluation for evidence of myocardial ischemia, including EKG and serum troponin levels

Sublingual nitroglycerin tablets, until an infusion of nitroglycerin can be initiated

Calcium gluconate, $$500$$ mg IV

The relative dilution of clotting factors due to plasma volume expansion during gestation

Previous postpartum hemorrhage

Protracted prolonged labor

Retained products of conception

Multiple previous uterine surgeries

Latent phase, transition, active phase, second stage, fetal descent, neonatal delivery, third stage, placental delivery

First stage, latent phase, active phase, second stage, transition, fetal descent, neonatal delivery, third stage, placental delivery

Latent phase, transition, active phase, second stage, neonatal delivery, third stage, placental delivery

Latent phase, active phase, transition, fetal descent, second stage, neonatal delivery, third stage, placental delivery

None of the above

Anesthetics can be provided by epidural medications.

Blood products may be required and should be requested early if bleeding appears significant.

Retained placenta is always an emergency that requires neuraxial or general anesthesia as quickly and safely as possible.

If significant blood loss has occurred and has not been corrected, epidural local anesthetics are contraindicated.

Intravenous nitroglycerin, $$50$$ to $$100$$ micrograms, can be used to relax the cervical os if it has contracted after delivery of the neonate.

The patient has true cholinesterase deficiency

Pregnancy induces production of atypical pseudocholinesterase

Prolongation of neuromuscular blockade is due to the aminoglycoside antibiotic (gentamicin) she received for prophylaxis of group B streptococcus.

The prolongation of neuromuscular blockade is due to the magnesium sulfate she received for seizure prophylaxis.

The sympathetic neuraxial labor analgesia results in decreased uteroplacental blood flow, which always compromises the fetus.

Severe preeclampsia is associated with thrombocytopenia.

Severe preeclampsia is associated with the development of coagulopathy.

Patients with preeclampsia are at risk for placental abruption.

Spinal anesthesia results in an incidence and degree of hypotension less than that in women who do not have preeclampsia.

She would be at risk for aspiration of gastric contents if general anesthesia were required.

She has remained NPO for greater than 6 hours after her last meal; therefore, her stomach is empty and she is not at increased risk of gastric aspiration.

The risk of gastric aspiration is increased in the parturient regardless of NPO status.

Rapid-sequence induction with cricoid pressure would be appropriate if this patient required general anesthesia.

Gastric aspiration can occur at both induction and emergence of anesthesia.

Decreased uteroplacental blood flow

Increased systemic vascular resistance

Hyperdynamic cardiac function

Increased central venous and pulmonary artery wedge pressures

Increased systemic blood pressure

Splenomegaly

Hepatic subcapsular hematoma

Proteinuria

Subarachnoid hemorrhage

Pulmonary edema

Minute ventilation is decreased due to the decreased excursion of the diaphragm from the impingement of the gravid uterus.

Minute ventilation is similar to the normal, nonpregnant levels due to an increase in respiratory rate.

There is evidence of a moderate to severe restrictive physiology as evidenced by flow-volume loop analysis and the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1:FVC).

The increased minute ventilation results in decreased maternal arterial carbon dioxide concentration (PaCO2).

Due to the impingement of the gravid uterus on the diaphragm, the term parturient is nearly $$100\%$$ dependent on intercostal and accessory muscles for ventilation.

Etomidate

Fentanyl

Esmolol

Succinylcholine

Lidocaine

The placental barrier reduces the serum concentration of these medications to only $$10$$ to $$20\%$$ of the maternal serum concentration.

The fetal muscles are resistant to all neuromuscular blocking medications because the neuromuscular endplate of striated muscle is immature.

The rapid metabolism of these medications in the fetal liver results in very low serum concentrations in the fetus.

Succinylcholine does not cross the placenta, but the steroid-based nondepolarizing medications (vecuronium, pancuronium, etc.) do cross and result in clinically significant weakness.

None of the above is correct.

The ionic charge of the molecule

The size of the uteroplacental surface area

The concentration difference between the mother and the fetus

The maternal blood pressure

The size of the molecule

A decrease in minute ventilation due to reduction of pulmonary functional residual capacity from the gravid uterus

An increase in systemic vascular resistance in response to an increase in cardiac output

Peripheral edema resulting from systolic ventricular dysfunction with a concomitant increase in central venous pressure and pulmonary capillary wedge pressure

A decrease in serum hemoglobin concentration despite increased red cell production

None of the above is correct.

Fetal oligohydramnios

Premature in utero closure of the ductus arteriosus

Maternal peptic ulcers

Gestational hypertension

Maternal renal dysfunction

Expansion of the collapsed lungs with air

Closure of the foramen ovale

Decreased pulmonary vascular resistance

Increased systemic vascular resistance

Patent ductus arteriosus

Immediate laryngoscopy and endotracheal intubation

Umbilical vein catheterization and administration of epinephrine

Intraosseous administration of isotonic crystalloid

Vigorous stimulation by drying the neonate with towels followed by assessment of its status

Oropharyngeal suction and mask ventilation with $$100\%$$ oxygen followed by chest compressions when a second person is available

Assess the effectiveness of the epidural catheter, including quality of analgesia and dermatomal sensory blockade

Administer ephedrine to improve uterine artery blood flow

Remove the epidural catheter and convert to intramuscular analgesia with opioids

Eliminate any opioid from the epidural solution to avoid fetal narcosis

Administer 3% chloroprocaine, 15 to 20 mL, in anticipation of the cesarean delivery

1

2

3

4

5

Inhibits the release of acetylcholine at the neuromuscular junction

Decreases the sensitivity of the neuromuscular junction to acetylcholine

Depresses the excitability of the muscle fiber membrane

Increases the potency and duration of vecuronium, rocuronium, and mivacurium

Increases the duration of a single intubating dose of succinylcholine

Functional residual capacity (FRC) begins to fall at the fifth month of pregnancy and is decreased to 80% of that of prepregnancy capacity by term.

Vital capacity is significantly decreased by term pregnancy.

A 25% reduction in expiratory reserve volume and a 15% reduction in residual volume account for the change in FRC.

Inspiratory capacity increases by 15% during the third trimester because of the increases in tidal volume and inspiratory reserve volume.

The decrease in FRC is due to elevation of the diaphragm caused by the enlarging uterus.

Hemorrhagic shock

Disseminated intravascular coagulation (DIC)

Intrauterine growth retardation

Placenta accreta

Acute renal failure

The parturient should have uterine displacement in the operating room to prevent aortocaval compression.

Medications with anticholinesterase effects are contraindicated because they may increase uterine tone and precipitate preterm labor.

The decision to monitor the fetal heart rate continuously should be considered but is individualized depending on each case, the ease of monitoring, and the site of surgery.

Induction could include thiopental, fentanyl, and succinylcholine.

Pregnant women are at risk for acid aspiration after 18 to 20 weeks gestation; pharmacologic precautions may be warranted.

Heparin

Glycopyrrolate

Thiopental

Succinylcholine

Rocuronium

Immediate intubation with endotracheal suctioning

Expectant management with empiric antibiotics

Steroids to treat pulmonary inflammation

Routine oral/nasal suctioning with expectant management

Endotracheal suctioning followed by radiographic films once suctioning is cleared

Aortocaval compression

Maternal hypotension

Excessive uterine tone

Fetal hypoxemia

Intermittent umbilical cord compression

Chest compressions at a rate of 90 compressions/minute

Epinephrine 0.01 mg/kg through an umbilical venous line

100 mL of isotonic crystalloid solution through an umbilical venous line

Observational care with blow-by oxygen

Gentle endotracheal intubation with positive-pressure ventilation

Hemoglobin F has a greater oxygen affinity than adult hemoglobin.

The P50 of fetal blood is approximately 27 mm Hg.

In fetal blood, hemoglobin F is approximately 75% to 84% of total hemoglobin.

The shift in fetal blood oxygen affinity can be explained by a decreased interaction between hemoglobin F and 2,3-DPG.

Fetal hemoglobin can be detected for up to 3 months after birth.

Beginning at 18 to 20 weeks gestation, left uterine displacement should be used to prevent aortocaval compression.

Scientific evidence supports the avoidance of nitrous oxide during pregnancy, especially after the 6th week of pregnancy.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used until the second half of pregnancy, at which time they should be used with caution.

The second trimester is the optimal time to perform surgery because the risk of preterm labor is lowest during that time.

Most structural abnormalities resulting from exposure to teratogenic agents occur between day 31 and day 71 after the first day of the last menstrual period.

Diabetes mellitus

Vascular/connective tissue disease

Nulliparity

Obesity

Smoking

Similar to that in the general obstetric population

Approximately 10%

Increased only if an endometrial strip is visible on ultrasound

Approximately 60%

At least 95%; all placenta previa is associated with accreta

Two large-gauge intravenous catheters and cross-matched packed red blood cells should be available.

The blood loss in an elective cesarean hysterectomy is comparable with an emergent cesarean hysterectomy.

Anesthetic options include continuous spinal anesthesia, combined spinal-epidural anesthesia, continuous epidural anesthesia, and general anesthesia.

In the event of conversion to general anesthesia from neuraxial anesthesia, the intravascular volume deficit may be underestimated and care should be taken in the selection and dosing of induction agents.

The choice of anesthetic technique has little influence on the degree of blood loss.

Results from the stimulation of visceral afferents that innervate the lower uterine segment and cervix and enter the spinal cord at L4 and L5 segments

Can lead to high concentrations of catecholamines. Labor analgesia reduces plasma concentrations of epinephrine and its associated effects on the myometrium.

Can be reliably treated by a pudendal block

Can be reliably treated by a paracervical block

Is necessary for the course of labor to proceed efficiently

Unrecognized placement of the catheter in the subarachnoid space

Overdose of local anesthetic in the epidural space

Migration of the epidural catheter into an epidural vein

Subdural injection of local anesthetic

Seizure from eclampsia

Tinnitus

Cerebral edema

Cranial nerve VI palsy

Seizures

Diplopia

Volatile anesthetics reduce blood pressure, which may result in reduced uterine blood flow.

Volatile agents cross the placenta and equilibrate rapidly with fetal tissues.

High levels of volatile agents may build up in the neonatal fat and can redistribute to the neonatal circulation, causing a secondary depression of ventilation.

End-tidal level of halogenated agents greater than 1 to 1.5 times the minimum alveolar concentration may reduce the effect of oxytocin on uterine tone.

The minimum alveolar concentration in pregnancy is higher than in nonpregnant women.

The upward displacement of the stomach and esophagus results in a reduction of tone of the lower esophageal barrier.

Gastric emptying of liquid and solid materials is slowed during pregnancy.

Esophageal peristalsis is slowed during pregnancy.

Gastric emptying is slowed during labor.

Pregnancy is a risk factor for difficulty during intubation.

Idiopathic/autoimmune thrombocytopenic purpura (ITP/ATP)

Gestational thrombocytopenia

Preeclampsia

Thrombotic thrombocytopenic purpura

Disseminated intravascular coagulopathy

Initiate epidural placement because pregnancy is a hypercoagulable state and lessens the severity of vWD.

Offer a remifentanil IV PCA.

Offer a remifentanil IV PCA and initiate DDAVP infusion.

Offer a remifentanil IV PCA and initiate cryoprecipitate.

Offer a remifentanil IV PCA and initiate Humate-P.

Are unaffected, as maternal antibodies to the acetylcholine receptor are IgM antibodies and do not cross the placenta.

Are affected approximately 75% of the time.

May need to take immunosuppressant therapy for a minimum of 2 to 3 weeks.

May need to take anticholinesterase therapy for 2 to 3 weeks.

Are unaffected immediately after birth but become symptomatic after 4 to 6 weeks.

Meningocele

Spina bifida occulta

Occult spinal dysraphism

Myelomeningocele

L1/S3—L3/S2

L3/S3—L1/S2

L1/L1—L3/L3

L1/S2—L3/S3

L3/L3—L1/L1

Stroke volume increases by 20% to 50%.

Cardiac output increases by 30% to 50%.

Central venous pressure increases by 3 to 5 mm H2O.

There is a 20% decrease of systemic vascular resistance.

There is a 30% decrease of pulmonary vascular resistance.

Increased incidence of motor blockade

Increased incidence of pruritus

Increased incidence of breakthrough pain

Increased incidence of hypotension

Increased incidence of respiratory depression

The spinal reflex inhibition of the gastrointestinal (GI) tract remaining unaffected

Similar pulmonary complications as intrapleural and intercostal block

Attenuating spinal reflex inhibition of diaphragmatic function

No effect in size of myocardial infarction compared to lumbar epidural

No change in coronary blood flow

An axillary block would be the best option since it has least likelihood of complications, including pneumothorax.

An interscalene block would be best to cover all sensory nerves to the upper arm, including the intercostobrachial nerve.

A supraclavicular block is performed at the level of the cords and can effectively block the brachial plexus for the upper arm.

An infraclavicular block is performed at the distal trunks and can be used to provide adequate sensory block for the surgery.

The surgery can be performed with sedation and local infiltration of anesthesia provided by the surgeon.

Posterior tibial nerve

Sural nerve

Saphenous nerve

Deep peroneal nerve

Superficial peroneal nerve

A labor epidural is not indicated if patient has a T5-level transaction if she has no motor or sensory function below T5.

Autonomic hyperreflexia does not develop if the lesion is below spinal dermatome T7.

Use of succinylcholine is contraindicated.

Hypertension, flushing, and headaches are likely signs of preeclampsia in this patient.

Because of lack of sensory connection to the cortex, a full bladder is well tolerated in this patient.

Axillary nerve

Musculocutaneous nerve

Median nerve

Ulnar nerve

Intercostal brachial nerve

Median nerve block can be evaluated by testing the lateral aspect of the ring finger.

Radial nerve block can be evaluated by testing the posterolateral aspect of the hand.

Ulnar nerve block can be evaluated by testing the medial aspect of the ring finger.

Median nerve block can be evaluated by testing the medial aspect of the palm.

Radial nerve block can be evaluated by testing the lateral aspect of the dorsum of the hand.

CNS stimulation is often followed by CNS depression via blockade of inhibitory pathways.

The ratio of dose required to induce cardiovascular collapse (CC) to the dose required for CNS effects [CC/CNS] is higher for bupivacaine than for lidocaine.

Succinylcholine administration to a patient with a tonic clonic seizure may contribute to metabolic acidosis.

Hyperventilation may lead to more CNS toxicity.

Combined metabolic and respiratory acidosis may further exacerbate CNS toxicity.

0.5% racemic bupivacaine

0.5% R(+) bupivacaine

0.5% S(−) bupivacaine

0.5% levo-bupivacaine

0.5% ropivacaine

0.75% bupivacaine

2% lidocaine

0.75% levobupivacaine

0.75% ropivacaine

2% mepivacaine

Lidocaine has a negative inotropic action on cardiac muscle in a dose-dependent fashion.

Lidocaine has antiarrhythmic properties while bupivacaine exhibits arrhythmogenic properties.

Bupivacaine depresses rapid depolarization in Purkinje fibers but lidocaine speeds up rapid depolarization.

High local anesthetic concentrations can lead to an increased PR interval and width of the QRS complex.

Lidocaine cardiac toxicity may be observed in cases involving tumescent anesthesia.

The celiac plexus contains afferent and efferent fibers from T5–T12 roots.

The plexus is blocked just anterior to the T8 vertebral body.

The celiac plexus innervates most of the abdominal viscera.

A celiac plexus block perioperatively can decrease body stress and endocrine response to surgery.

Complications include aspiration of blood, urine, or CSF from the needle.

Phrenic nerve blockade is a rare complication of deep cervical plexus block.

The superficial cervical plexus innervates the sternocleidomastoid muscle.

A deep cervical plexus block is performed at the level of the C4, C5, and C6 levels.

A superficial cervical plexus block is performed at the anteromedial aspect of the sternocleidomastoid muscle.

The only major blood vessels at risk during a deep cervical plexus block are the carotid artery and the jugular vein, and both can easily be avoided.

Cocaine acts as a sodium channel blocker.

Cocaine causes release of catecholamines, leading to hypertension and tachycardia.

Cocaine is an aminoester.

Cocaine blocks reuptake of catecholamines, leading to cerebrovascular accidents, myocardial infarctions, and arrhythmias.

Cocaine is metabolized by hepatic carboxylesterases.

Small nonmyelinated C fibers are most susceptible to local anesthetic blockade.

Large myelinated Aα and Aβ are most susceptible to local anesthetic blockade.

Small myelinated B fibers are most susceptible to local anesthetic blockade.

Fibers carrying proprioception are more susceptible than fibers carrying cold sensation.

Small nerve fibers are more susceptible than larger fibers.

Neurotoxicity

Pruritus

Hypotension

Respiratory depression

Reactivation of oral HSV infection

It is a midline connective tissue band visualized on epiduroscopy.

It extends from the dura mater toward the ligamentum flavum.

It may lead to difficult catheter insertion.

It may lead to unilateral epidural block.

It may lead to unilateral spinal block.

Exists between the dura mater and arachnoid mater

Contains CSF

Exists between the dura mater and ligamentum flavum

Can be easily found in all patients

Will produce reliable anesthesia and analgesia

Decreased stroke volume and cardiac output

Decreased mean arterial pressure

Decreased peripheral vascular resistance

Decreased resting minute ventilation

Unchanged dead space

Spinal anesthesia increases temperature threshold for sweating.

Spinal anesthesia decreases temperature threshold for vasoconstriction.

Spinal anesthesia decreases temperature threshold for shivering.

Intravenous administration of lidocaine, with equivalent plasma levels, alters thresholds for vasoconstriction and shivering similar to epidural administration of lidocaine.

The intensity of shivering is decreased by neuraxial anesthesia.

Reduce minute ventilation

Increase the respiratory rate

Increase the work of breathing

Lower PaO2

Reduce expiratory reserve volume

Use of opiates in the epidural solution leads to a higher incidence of respiratory depression compared to a patient-controlled intravenous administration of opiates.

Both fentanyl and hydromorphone infusion in equipment doses provide the same analgesic potency in a lumbar epidural for this patient.

The analgesic site of action for continuous infusion of a hydrophilic opiate is systemic.

A bolus of hydrophilic opiate will provide a more rapid onset of analgesia than a bolus of a lipophilic opiate.

A single bolus of fentanyl 100 mcg in the epidural space is an appropriate step in treating breakthrough pain in this patient.

Hemodynamic changes that occur after an epinephrine-containing test dose solution lead to decreased uteroplacental perfusion in an obstetric patient.

Injection of 15 mcg of epinephrine should yield a 15- to 20-bpm rise in heart rate if the catheter is intravascular.

Injection of 1 mL of air and hearing a mill-wheel murmur over the right heart with a Doppler is an appropriate test for intravascular injection.

Aspiration from a single-orifice catheter is more sensitive in detecting an intravascular epidural catheter compared to a multi-orifice catheter.

Injection of lidocaine 100 mg without epinephrine is an appropriate test dose to detect intravascular and/or intrathecal catheter placement.

Neuraxial anesthesia blunts the body’s stress response to surgery.

Neuraxial anesthesia leads to increased bleeding due to vasodilation.

Neuraxial anesthesia decreases the incidence of postoperative thromboembolic events.

Neuraxial anesthesia decreases perioperative morbidity and mortality in high-risk patients.

Neuraxial anesthesia can be used to extend analgesia into the postoperative period.

Spinal anesthesia with bupivacaine and morphine sulfate (Duramorph)

Femoral and obturator nerve block

Femoral and popliteal nerve block

Fascia iliaca block

The femoral nerve is located below both the fascia lata and fascia iliaca.

Stimulation of the sartorius muscle will lead to reliable anesthesia in the femoral nerve distribution.

The femoral nerve is approximately 1 cm medial to the femoral artery.

A femoral nerve block can provide complete anesthesia for a femoral fracture.

The needle entry point for a fascia iliaca block is at the intersection of the lateral two-thirds and the medial one-third of the line connecting the pubic tubercle and anterior superior iliac spine (inguinal ligament).

Posterior cutaneous branch

Anterior cutaneous branch

Medial cutaneous branch

Lateral cutaneous branch

Gray ramus communicans

Walking off cephalad from the rib and injecting 3 to 5 mL of local anesthetic at the angle of the rib posteriorly

Walking off cephalad from the rib and injecting 3 to 5 mL of local anesthetic 3 to 5 cm anterior to the insertion site

Walking off caudad from the rib and injecting 3 to 5 mL of local anesthetic just lateral to the sternum

Walking off caudad from the rib and injecting 3 to 5 mL of local anesthetic at the angle of the rib posteriorly

Walking off caudad from the rib and injecting 3 to 5 mL of local anesthetic just anterior to the insertion site

Adjacent to the brachial artery at the level of the elbow

At the groove formed by the olecranon and medial condyle of the humerus

At the level of the wrist, lateral to the radial artery near the tendons of the extensor pollicis brevis and extensor pollicis longus

At the upper arm, into the body of the coracobrachialis muscle

At the elbow level, 2 cm lateral to the biceps tendon

Use of epidural analgesia — Increased motility

Nitrous oxide — Decreased motility

Volatile anesthetics — Increased motility

Intravenous local anesthetics — Increased motility

Splanchnic nerve blockade — Increased motility

10 mL of 0.5% bupivacaine

10 mL of 1% lidocaine

10 mL of 0.25% bupivacaine

20 mL of 0.125% bupivacaine

50 mL of 0.5% lidocaine

Deflate the tourniquet and perform an axillary block.

Deflate the tourniquet after 30 minutes and perform general anesthesia.

Deflate the tourniquet and perform general anesthesia.

Maintain the tourniquet and wait for the instruments.

Inject more lidocaine into the anesthetized hand to allow the block to last longer.

Patients receiving fractionated low–molecular-weight heparin (LMWH) preoperatively at thromboprophylactic doses should have the drug held for 12 hours before performing a neuraxial block.

There is no significant added risk of spinal hematomas for patients taking aspirin to undergo a neuraxial block.

Clopidogrel should be discontinued for 1 week, and ticlopidine for 2 weeks, prior to placing a neuraxial block.

Patients receiving thrombolytic therapy should wait 12 hours before receiving a neuraxial block.

There is no contraindication to performing a neuraxial block for patients on unfractionated heparin dosed at 5,000 units twice a day.

Procaine < lidocaine ≈ mepivacaine < bupivacaine

Mepivacaine < lidocaine ≈ bupivacaine < ropivacaine

Mepivacaine < lidocaine < ropivacaine < bupivacaine

Lidocaine < mepivacaine < prilocaine < bupivacaine

Procaine < mepivacaine < lidocaine < bupivacaine

Pediatric patients have an increased volume of distribution.

Pediatric patients have increased protein binding of local anesthetics.

Pediatric patients have increased enzymatic activity and breakdown of local anesthetics.

Pediatric patients have decreased systemic absorption of local anesthetics.

Adding epinephrine to local anesthetics is not as effective in prolonging blocks compared to adults.

Commercially available premixed solutions of local anesthetics with epinephrine are more basic in order to preserve the potency of epinephrine.

Epinephrine added to ropivacaine will intensify blockade but not prolong the duration of an epidural block.

Epinephrine can more effectively prolong the effects of lidocaine and 2‑chloroprocaine than bupivacaine.

The addition of epinephrine can more effectively decrease plasma lidocaine and 2‑chloroprocaine levels than plasma bupivacaine levels.

Epinephrine contributes to analgesia in the neuraxis due to its presynaptic adrenergic receptor activity.

Addition of 1 mL of 8.4% NaHCO₃ (sodium bicarbonate) to 9 mL of 2% lidocaine will increase the speed of onset of a neuraxial block.

Alkalinization of bupivacaine will decrease the time of onset of an epidural block.

Alkalinization of ropivacaine does not result in a faster onset of block.

Alkalinization of ropivacaine is less likely to result in precipitation than alkalinization of bupivacaine.

Alkalinization of a local anesthetic solution increases the un‑ionized fraction of anesthetic.

2‑chloroprocaine

Lidocaine

Ropivacaine

Mepivacaine

Any other local anesthetic

Femoral, sciatic

Popliteal, saphenous

Sural, saphenous, deep peroneal, superficial peroneal, posterior tibial

Obturator, sciatic, sural, posterior tibial

Common peroneal, tibial, femoral

Radial nerve

Ulnar nerve

Musculocutaneous nerve

Recurrent branch of the median nerve

Median nerve

A stat portable chest x‑ray

Co‑oximetry analysis of an arterial blood gas

CT of his chest

Continued bronchoscopy will reveal the etiology of his respiratory failure.

A transesophageal echocardiogram

Most allergic reactions to methylparaben are IgE‑mediated.

Cross‑sensitivity between methylparaben and ester‑type local anesthetics does occur.

Antimicrobial activity from methylparaben and similar preservatives is temperature‑dependent.

Methylparaben in combination with lidocaine has greater bactericidal activity than lidocaine alone.

Methylparaben alone is a less effective antimicrobial agent than when combined with a local anesthetic.

Lumbar plexus

Femoral nerve, lateral femoral cutaneous nerve, sciatic nerve

Lumbar plexus, obturator nerve, lateral femoral cutaneous nerve

Femoral nerve, sciatic nerve, obturator nerve

Femoral nerve, lateral femoral cutaneous nerve, popliteal fossa

10 mL of 0.5% bupivacaine

10 mL of 3% 2‑chloroprocaine with epinephrine

10 mL of 0.5% ropivacaine

10 mL of 2% lidocaine

10 mL of 2% mepivacaine with epinephrine

The afferent pathway involves the ophthalmic division of the trigeminal nerve, and the efferent pathway is mediated by the vagus nerve.

The ciliary and gasserian ganglions are involved in the pathway.

Deep anesthesia potentiates this pathway and should be avoided.

The OCR can occur during placement of a retrobulbar block.

The OCR can result in ventricular fibrillation and nodal rhythms.

Infections with the use of a caudal catheter

A postdural puncture headache

Seizures

Total spinal anesthesia

Profound hypotension with a caudal injection to the T6 level

The dural sac ends at a lower level

The CSF volume per kilogram of body weight is less

“Loss of resistance” is usually more prominent during placement of an epidural

The upper limit to local anesthetic dosing is greater than in adults

Volume of distribution of local anesthetic is smaller than in adults

Trigeminal, glossopharyngeal, superior laryngeal

Facial, glossopharyngeal, superior laryngeal, recurrent laryngeal

Trigeminal, glossopharyngeal, recurrent laryngeal

Lingual, glossopharyngeal, superior laryngeal

Maxillary, glossopharyngeal, superior laryngeal

Injection with phenol is more painful than injection with alcohol.

Peripheral neurolysis with alcohol, but not phenol, can lead to denervation pain.

Alcohol neurolysis is more intense.

Alcohol has a biphasic action as a local anesthetic and a neurolytic.

Neurolysis with phenol is usually permanent.

Nociceptors are present at the free nerve endings of C and Aδ fibers.

The amount of neural activity in nociceptive effects does not depend on intensity and duration; it is an all‑or‑none response.

Skin rubbing and vibration may decrease the nociceptive neuronal activity.

Sensitization of nociceptors occurs by repeated noxious stimuli.

Primary hyperalgesia is associated with a lowered pain threshold and spontaneous pain.

A prodrome of dermatomal pain usually precedes the appearance of a rash.

The majority of patients with herpes zoster will develop postherpetic neuralgia (PHN).

Sympathetic nerve blocks can reliably reduce pain in patients with herpes zoster and PHN.

Injection lateral to the femoral artery, and injection inferolateral to the pubic symphysis

Injection in the fascial plane between the vastus medialis and sartorius, and injection at the popliteal fossa

Injections in the intermuscular fascial planes between the adductor brevis and adductor longus, and between the adductor brevis and adductor magnus

Injection medial to the femoral artery, and injection at the popliteal fossa

Injection in the psoas compartment, and injection between the vastus medialis and sartorius

Injection lateral to the subclavian artery above the first rib

Injection medial to the subclavian artery above the first rib

Injection between the sternocleidomastoid and anterior scalene at the level of the cricoid cartilage

Injection beneath the middle scalene muscle at the level of the cricoid cartilage

Injection around the axillary vein and beneath the pectoralis major and minor muscles using the infraclavicular approach

Paracervical block

Pudendal block

Caudal block

Paravertebral lumbar sympathetic block

Continuous spinal block

Inadvertent intra-arterial injection

Stimulation of the oculocardiac reflex (OCR)

Retrobulbar hemorrhage

Brainstem anesthesia

Too much intravenous sedation was administered prior to block placement

Greater trochanter, sacral hiatus, posterior superior iliac spine

Greater trochanter, sacral hiatus, iliac crest

Greater trochanter, sacral hiatus, anterior superior iliac spine

Greater trochanter, ischial tuberosity, sacral hiatus

Anterior superior iliac spine, pubic tubercle

The radial nerve

The median nerve

The medial cutaneous nerve of the forearm

The lateral cutaneous nerve of the forearm

The intercostobrachial nerve

Anterior cord

Lateral cord

Medial cord

Posterior cord

Lateral and posterior cords

Hypotension

Bradycardia

Decreased right-sided filling pressures

Decrease in total peripheral resistance

An increase in preload

It happens more commonly in patients with increased age.

It usually resolves spontaneously for most patients.

Bedrest, analgesics, and caffeine can produce relief of symptoms.

It is more common in parturients.

The headache is usually worsened by head elevation and occurs in a fronto-occipital distribution.

A decrease in dead space

An increase in PaCO_2

Dyspnea due to hypoxemia

A decrement in active exhalation

Impairment in diaphragmatic function

Ephedrine 10 mg IV

Phenylephrine 100 mcg IV

Intravenous fluid bolus and Trendelenburg position

Epinephrine 5 mcg IV

Epinephrine 10 mcg IV

Injection into the basilar artery

Injection into the vertebral artery

Injection into the carotid artery

Injection into the internal jugular vein

Injection into the subclavian artery

A paramedian approach is generally less painful compared to a midline approach.

The needle insertion point is approximately 3 to 5 cm lateral to midline.

A paramedian approach requires less patient cooperation to reduce lumbar lordosis.

The L4–5 has the largest interlaminar space in the lumbosacral region and is used in the Taylor variation of the paramedian technique.

The paramedian approach is generally more difficult because a smaller opening is available to access the epidural and intrathecal space.

Place patient in Trendelenburg position.

Administer Intralipid.

Administer ephedrine.

Endotracheal intubation.

Administer epinephrine.

Administration of 60% nitrous oxide with oxygen through a mask

Administration of incremental intravenous ketamine 0.1 to 0.25 mg/kg

Conversion to general anesthesia

Reassurance of the patient that analgesia is adequate since it was tested before the incision

Small boluses of intravenous fentanyl

A 30-year-old term parturient

A 24-year-old woman with a BMI of 40

A 50-year-old man with a large abdominal tumor

A 45-year-old woman with significant abdominal ascites

A 35-year-old man with myasthenia gravis

The adult subarachnoid space extends from the foramen magnum to S2.

Injection of local anesthetic below the L1 level in adults should avoid direct trauma to the cord.

Injection of local anesthetic below the L2 level in children should avoid direct trauma to the cord.

Injection of local anesthetic below the L3 level in children should avoid direct trauma to the cord.

The subarachnoid space extends from the foramen magnum to S3 in children.

Posterior longitudinal ligament

Ligamentum flavum

Supraspinous ligament

Intraspinous ligament

Dura mater

Skin, subcutaneous tissue, intraspinous ligament, epidural space, ligamentum flavum, dura

Skin, subcutaneous tissue, supraspinous ligament, intraspinous ligament, ligamentum flavum, epidural space, dura, pia

Skin, subcutaneous tissue, intraspinous ligament, ligamentum flavum, epidural space, ligamentum flavum, dura, pia

Skin, subcutaneous tissue, supraspinous ligament, intraspinous ligament, ligamentum flavum, epidural space, dura, arachnoid

Skin, subcutaneous tissue, supraspinous ligament, intraspinous ligament, ligamentum flavum, epidural space, dura, pia, arachnoid

Meralgia paresthetica

An intrathecal hematoma

Cauda equina syndrome

Transient neurologic symptoms

An abscess is developing near the subarachnoid space due to inadequate sterile precautions prior to block placement.

Bilateral injections of 2 mL of 1% lidocaine into the base of the anterior tonsillar pillar

An injection of 4 mL of 4% lidocaine through the cricothyroid membrane into the trachea

Bilateral injections of 2 mL of 1% lidocaine at the level of the thyrohyoid membrane just below the greater cornu of the thyroid cartilage

Placing local anesthetic-soaked swabs against the inferior aspects of the palatoglossal folds

Bilateral injections of 10 mL of 1% lidocaine at the posterior border of the sternocleidomastoid at and near the level of C4

A decreased incidence of wound complications

Decreased pain in the postoperative period

Acute pulmonary edema upon tourniquet release

Quicker recovery of muscle power postoperatively

Lack of electromyographic changes postoperatively

Increasing the gain will lead to improved resolution.

Increasing the frequency will lead to improved resolution.

Decreasing the frequency will lead to improved resolution.

Decreasing the gain will lead to improved resolution.

Neither gain nor frequency has any effect on the resolution of the image.

Identification of the nerves and other anatomic structures provides an advantage for using ultrasound.

Observation of the needle and the spread of local anesthetic is possible using ultrasound.

Studies have shown that a decreased volume of injected local anesthetic is needed if using an ultrasound technique compared to a nerve stimulator technique.

Randomized clinical trials have shown that complication rates are lower with the use of an ultrasound technique.

Performing a nerve block with a nerve stimulator can be more painful for patients compared to an ultrasound technique.

Middle scalene muscle

Anterior scalene muscle

Adjacent to the phrenic nerve

Sternocleidomastoid muscle

Adjacent to the internal jugular vein

Transversus abdominis plane between the internal oblique and transversus abdominis muscles

Rectus sheath posterior to the rectus abdominis muscle

Ilioinguinal/iliohypogastric plane at the level of the anterior superior iliac spine

Thoracic paravertebral space at T8–T10

Subcutaneous infiltration along the incision