Exaggerated hypotension with anesthetics?

[gasp]

25 y/o F here for suction D&C for IUFD at 9 weeks. 65kg. No allergies and no medical history. Surgical Hx for suction D&C 2 years ago where the anesthesiologist told her that she became "severely hypotensive after induction". She has noting else to add after extensive questioning on what happend last time and no it was not because she was bleeding to death.

Not knowing what happened last time, I decided to tank her up with a Liter and have the usual neo and ephedrine ready on hand. I also decided to induce with Etomidate just in case she had some type of reaction to propofol. I induced with 20mg Etomidate, 25mcg Fentanyl, and 50mg Succ. Starting HR was 85 and BP was 108/61 which went down to 80's/40's after induction. Any gas would make it worse (used sevo, didnt have des). With some balance of fluids, neo, ephedrine, agent, and N2O case was finished in 15 mins but you could tell that there was exaggerated hypotension to the anesthetic.

I personally have never had a patient that responded this way. Has anyone had this happen to them and what do you think?

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[Noyac]

80/40 is not that low in a healthy 25yo under GA.
I understand that you used etomidate but it is very likely that this girls BP is lower than this every night while she sleeps. You just took away any anxiety she had.
I assume her mean pressure was 52. That should be plenty for her.

 

[gasp]

80/40 is not that low in a healthy 25yo under GA.
I understand that you used etomidate but it is very likely that this girls BP is lower than this every night while she sleeps. You just took away any anxiety she had.
I assume her mean pressure was 52. That should be plenty for her.

Yes, I understand that its not very low for her but 80's /40's was just induction alone. My concern is how fast and how much it dropped by given the circumstances including this story about her last D&C and the rest of the case. Her mean would start dipping into the low 40's easily if I had not used neo/ephedrine/more fluids/very low agent/N2O to compensate. It was just not a normal response.

 

[urge]

An echo would have been nice. Maybe she has HOCM or one of those things.

 

[deleted171991]

80/40 is not that low in a healthy 25yo under GA.
I understand that you used etomidate but it is very likely that this girls BP is lower than this every night while she sleeps. You just took away any anxiety she had.
I assume her mean pressure was 52. That should be plenty for her.

+1. She's probably around 80-90/40-50 at baseline.

Plus I would have done the case with an LMA.

 

[Noyac]

+1. She's probably around 80-90/40-50 at baseline.

Plus I would have done the case with an LMA.

For some stupid reason I just don't like doing D&C's with an LMA. Never had an issue but I just don't like it. I know everyone else does it that way but I can't come around.

 

[Brookstacular]

For some stupid reason I just don't like doing D&C's with an LMA. Never had an issue but I just don't like it. I know everyone else does it that way but I can't come around.

What about reduction in myalgias? No risk of prolonged neuromuscular blockade or pseudocholinesterase deficiency? Likely reduction in sore throat post op? Less cost in terms of drugs administered (though pretty marginal? Anecdotally, LMAs with some sevo or des, little bit of ketorac, and a deep LMA pull seems like less OR time and possibly PACU time.

 

[pgg]

25 y/o F here for suction D&C for IUFD at 9 weeks. 65kg. No allergies and no medical history. Surgical Hx for suction D&C 2 years ago where the anesthesiologist told her that she became "severely hypotensive after induction". She has noting else to add after extensive questioning on what happend last time and no it was not because she was bleeding to death.

Not knowing what happened last time, I decided to tank her up with a Liter and have the usual neo and ephedrine ready on hand. I also decided to induce with Etomidate just in case she had some type of reaction to propofol. I induced with 20mg Etomidate, 25mcg Fentanyl, and 50mg Succ. Starting HR was 85 and BP was 108/61 which went down to 80's/40's after induction. Any gas would make it worse (used sevo, didnt have des). With some balance of fluids, neo, ephedrine, agent, and N2O case was finished in 15 mins but you could tell that there was exaggerated hypotension to the anesthetic.

As mentioned 80s/40s isn't all that interesting. Anecdotally, I believe that letting mild hypotension ride through a general anesthetic increases PONV, so I don't like to look at it. But that's a pretty unremarkable BP for a young female under GA, minus any kind of stimulation.

I would not have used evomitate in a o/w healthy 25 yo with a vague story like that. Assuming an RSI was not indicated, you can do a gradual induction with propofol, +/- some sevo and/or ketamine. You don't have to flush the induction in with the muscle relaxant, if it's not a RSI there's no rush.

What about reduction in myalgias? No risk of prolonged neuromuscular blockade or pseudocholinesterase deficiency? Likely reduction in sore throat post op? Less cost in terms of drugs administered (though pretty marginal? Anecdotally, LMAs with some sevo or des, little bit of ketorac, and a deep LMA pull seems like less OR time and possibly PACU time.

Having your uterus prodded like that can be pretty nausea provoking so I really make an effort to avoid gas and opiates. I do almost all of my D&Cs and hysteroscopy/ablations with a simple face mask (+CO2 line), spontaneous ventilation, and some ketafol, assuming they're NPO. I usually limit the total ketamine dose to about 20 mg, ie 1 mg/mL for the first 20 mL propofol vial. Ketorolac and midazolam preop. Some fentanyl prior to cooking if part of the procedure is an ablation. Otherwise rarely need any opiate. Bypass PACU.

 

[Brookstacular]

As mentioned 80s/40s isn't all that interesting. Anecdotally, I believe that letting mild hypotension ride through a general anesthetic increases PONV, so I don't like to look at it. But that's a pretty unremarkable BP for a young female under GA, minus any kind of stimulation.

I would not have used evomitate in a o/w healthy 25 yo with a vague story like that. Assuming an RSI was not indicated, you can do a gradual induction with propofol, +/- some sevo and/or ketamine. You don't have to flush the induction in with the muscle relaxant, if it's not a RSI there's no rush.




Having your uterus prodded like that can be pretty nausea provoking so I really make an effort to avoid gas and opiates. I do almost all of my D&Cs and hysteroscopy/ablations with a simple face mask (+CO2 line), spontaneous ventilation, and some ketafol, assuming they're NPO. I usually limit the total ketamine dose to about 20 mg, ie 1 mg/mL for the first 20 mL propofol vial. Ketorolac and midazolam preop. Some fentanyl prior to cooking if part of the procedure is an ablation. Otherwise rarely need any opiate. Bypass PACU.

Seems like a nice technique. PONV is such a beast in these cases and the whopping 1.3 MAC necessary to keep them comfy is surely vomit inducing.

 

[Noyac]

What about reduction in myalgias? No risk of prolonged neuromuscular blockade or pseudocholinesterase deficiency? Likely reduction in sore throat post op? Less cost in terms of drugs administered (though pretty marginal? Anecdotally, LMAs with some sevo or des, little bit of ketorac, and a deep LMA pull seems like less OR time and possibly PACU time.

Totally agree with you. However, I rarely use sux. I just use 4% atomized Lido LTA. And pass the tube. Pt never sees a muscle relaxant and lido is not a charged item so even cheaper. Rarely have anyone complain of sore throat. Actually, rarely have any complaints from any cases of a sore throat. Don't know why. And I do ask.

 

[Noyac]

Seems like a nice technique. PONV is such a beast in these cases and the whopping 1.3 MAC necessary to keep them comfy is surely vomit inducing.

I can't remember the last time in had one of these pt experience PONV. SERIOUSLY!
This is about as simple as it gets. Minus the completely pale hypotensive bleeding profusely morbidly obese with. 22g PIV.

 

[chmd]

I'm really happy we do these cases as macs. It sucks to recover them as is, would hate to deal w them after a geta

 

[gasdoc77]

Did

25 y/o F here for suction D&C for IUFD at 9 weeks. 65kg. No allergies and no medical history. Surgical Hx for suction D&C 2 years ago where the anesthesiologist told her that she became "severely hypotensive after induction". She has noting else to add after extensive questioning on what happend last time and no it was not because she was bleeding to death.

Not knowing what happened last time, I decided to tank her up with a Liter and have the usual neo and ephedrine ready on hand. I also decided to induce with Etomidate just in case she had some type of reaction to propofol. I induced with 20mg Etomidate, 25mcg Fentanyl, and 50mg Succ. Starting HR was 85 and BP was 108/61 which went down to 80's/40's after induction. Any gas would make it worse (used sevo, didnt have des). With some balance of fluids, neo, ephedrine, agent, and N2O case was finished in 15 mins but you could tell that there was exaggerated hypotension to the anesthetic.

I personally have never had a patient that responded this way. Has anyone had this happen to them and what do you think?

s

25 y/o F here for suction D&C for IUFD at 9 weeks. 65kg. No allergies and no medical history. Surgical Hx for suction D&C 2 years ago where the anesthesiologist told her that she became "severely hypotensive after induction". She has noting else to add after extensive questioning on what happend last time and no it was not because she was bleeding to death.

Not knowing what happened last time, I decided to tank her up with a Liter and have the usual neo and ephedrine ready on hand. I also decided to induce with Etomidate just in case she had some type of reaction to propofol. I induced with 20mg Etomidate, 25mcg Fentanyl, and 50mg Succ. Starting HR was 85 and BP was 108/61 which went down to 80's/40's after induction. Any gas would make it worse (used sevo, didnt have des). With some balance of fluids, neo, ephedrine, agent, and N2O case was finished in 15 mins but you could tell that there was exaggerated hypotension to the anesthetic.

I personally have never had a patient that responded this way. Has anyone had this happen to them and what do you think?

Did she get a dose of abx each time?

 

[gasp]

No she never got abx

 

[Planktonmd]

I think her normal systolic BP is probably 80-90 like many young healthy people and the initial BP you got in pre-op was probably elevated by anxiety and white coat syndrome.

 

[Guy Caballero]

If she returns to the OR, I would suggest...a retrograde wire.

 

[Smaug]

25 y/o F here for suction D&C for IUFD at 9 weeks. 65kg. No allergies and no medical history. Surgical Hx for suction D&C 2 years ago where the anesthesiologist told her that she became "severely hypotensive after induction". She has noting else to add after extensive questioning on what happend last time and no it was not because she was bleeding to death.

Not knowing what happened last time, I decided to tank her up with a Liter and have the usual neo and ephedrine ready on hand. I also decided to induce with Etomidate just in case she had some type of reaction to propofol. I induced with 20mg Etomidate, 25mcg Fentanyl, and 50mg Succ. Starting HR was 85 and BP was 108/61 which went down to 80's/40's after induction. Any gas would make it worse (used sevo, didnt have des). With some balance of fluids, neo, ephedrine, agent, and N2O case was finished in 15 mins but you could tell that there was exaggerated hypotension to the anesthetic.

I personally have never had a patient that responded this way. Has anyone had this happen to them and what do you think?

I usually expect young patients like that to maintain their pressures a bit better - even with propofol inductions - but what you saw does happen unexpectedly from time to time. And unfortunately (as I’m sure you know) there are a wide variety of reasons for it that you could delve into (if you had the time).

As for etomidate, I think you could go either way. Ketamine might have been a reasonable option as well.

 

[soorg]

Happens about once a year. Just deal. Not everyone has Grade I autonomics.

 

[deleted171991]

I can't remember the last time in had one of these pt experience PONV. SERIOUSLY!

I concur. The procedure is short, and the only patients who get nauseous from gas are the ones who have a history of bad PONV. Most of the time, it's the opiates.