Hawaiian Bruin

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JPP is back and posting? UTSW? Noy is out of the shadows? What is this forum coming to?

Since OB is the flavor of the month, here's my contribution.

23 yo G1, 40+2 wks, in active labor. Started complaining of headaches this morning, now with some viusal complaints as well. BP 165/92, HR 115. CBC from 6 hours ago: Hct 38, Plt 102.

A few weeks she back had a cough and fever and went to her PCP, who got a CXR which looked something like this (not the pt's actual CXR, but pretty close):


Neither OBs nor nurses appear to know about or care about this finding. The patient isn't the most educated mom-to-be ever and herself has little insight into this finding, or what workup happened afterward, though she says she was sent for some additional testing at some Outside Hospital.

Frequent lates, some pretty long, on the strip. Variability is good. OBs are getting nervous and are sporting their "I wanna cut right now" look.

Now what?
 

IlDestriero

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WTF is it? Aneurysm?
My bet is a diaphragmatic hernia from the increased abdominal pressure from her gravid uterus. I can't tell if it has air fluid levels or not. It could also be a nasty little anterior mediastinal mass. If it is, it's in a really dangerous looking place! Time to call a radiologist, or at least look at it on a box that can manipulate the image a bit to try to figure out what it is.
 

urge

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Mediastinal mass + preeclampsia?
 

pgg

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Does she already have an epidural?

Mediastinal mass has implications for GA, especially the RSI flavor usually used in parturients. Propofol/sux/tube could be a disaster. Severe pre-eclampsia with 100K platelets 6 hrs ago - probably deserves a recheck before doing anything electively neuraxial but you could defend a spinal right now if they call a stat section. Magnesium.

Shadow looks distinct from the aorta so I'd guess not an aneurysm.

And the OBs weren't interested in the CXR? :rolleyes:
 

IlDestriero

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Either way, it's an awesome thing to discover literally minutes before she goes back for her crash C/S. I'd get an epidural in now to avoid having to do GA for the section. Have the OB talk to the Radiologist and/or get a new AP and Lateral CXR now, while you're placing the epidural.
 

urge

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Mediastinal mass has implications for GA, especially the RSI flavor usually used in parturients. Propofol/sux/tube could be a disaster.
That thing looks to be more to the left. I bet she'll be a'right.

Pent sux tube!
 

IlDestriero

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See if she can lie flat. If she decompensates, the kid's probably not going to make it. I don't think the OB guys can do the section lateral. Sometimes they make it look hard with the patient supine.:laugh:
 

sevoflurane

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Good H&P. Ask about dyspnea/lying flat. I'd bet on lymphoma with her recent history of fever and cough.

Pre-eclamptic and may progress to eclampsia. She needs to deliver.

Spinal before GA is she can't lie flat or if there is anything that alerts me to difficulty ventilating. Platelet of 102 6 hours ago is likely above 75k, but I may repeat to make sure.
 

aredoubleyou

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That thing looks to be more to the left. I bet she'll be a'right.

Pent sux tube!
Anterior mass is supposedly, in truth, a pediatric concern and rarely causes significant problems with adults...so chances are you'd be right (although I sense your joking). That being said, I've had difficult to treat hypotension in such a patient (adult) almost immediatly after the pt was relaxed (following an inhalational induction) - so I am on board with the epidural. Can always induce with ketamine if youve gotta throw in an ETT, so long as its a mass and not an aorta ready to burst.
 

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That looks screwy.

Did the patient get a CXR on this admit too? She should get a PA and LAT.

If that thing's still there, I'd be on the phone with a radiologist trying to find the best way to have that thing imaged before we start cutting her open for C/S.
 

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If an anterior mediastinal mass was significant and causing some degree of airway compromise this woman would not have made it to term pregnancy.
In general the fear of anterior mediastinal masses is most of the times exaggerated, and even the ones with mild to moderate airway compromise can be mask ventilated without a problem.
This patient is having some decelerations and the OB wants to proceed with a c section, I would do a spinal anesthetic like every C section we do, if for some reason the spinal fails or we need to do a stat C section I will not hesitate to do RSI and intubate her like any other patient.
 

Hawaiian Bruin

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Good comments all.

There were no problems lying flat, and we managed to get in contact with the OSH, which revealed that she'd had a CT scan. The mass was prevascular, with no airway compression. Further workup had been deferred until after she delivered, it was presumed a likely lymphoma based on syxs.

So after much consternation, we decided her airway was not likely to be an issue, though the film gave us a good scare at first. It was surprising that "anterior mediastinal mass" didn't raise any red flags for the OBs, and you'd think they would have known the history and workup well, but waddya gonna do.

We asked for repeat plts, they were 70K. OK for spinal given the rapidity of this change?
 

ProRealDoc

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JPP is back and posting? UTSW? Noy is out of the shadows? What is this forum coming to?

Since OB is the flavor of the month, here's my contribution.

23 yo G1, 40+2 wks, in active labor. Started complaining of headaches this morning, now with some viusal complaints as well. BP 165/92, HR 115. CBC from 6 hours ago: Hct 38, Plt 102.

A few weeks she back had a cough and fever and went to her PCP, who got a CXR which looked something like this (not the pt's actual CXR, but pretty close):

Neither OBs nor nurses appear to know about or care about this finding. The patient isn't the most educated mom-to-be ever and herself has little insight into this finding, or what workup happened afterward, though she says she was sent for some additional testing at some Outside Hospital.

Frequent lates, some pretty long, on the strip. Variability is good. OBs are getting nervous and are sporting their "I wanna cut right now" look.

Now what?

Ant. mediastinal mass is high on the differential. Could also represent lingular pneumonia or a vascular ring.
 

monchi

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Good comments all.

There were no problems lying flat, and we managed to get in contact with the OSH, which revealed that she'd had a CT scan. The mass was prevascular, with no airway compression. Further workup had been deferred until after she delivered, it was presumed a likely lymphoma based on syxs.

So after much consternation, we decided her airway was not likely to be an issue, though the film gave us a good scare at first. It was surprising that "anterior mediastinal mass" didn't raise any red flags for the OBs, and you'd think they would have known the history and workup well, but waddya gonna do.

We asked for repeat plts, they were 70K. OK for spinal given the rapidity of this change?
I love these posted cases - I feel like I learn a ton.

So no mediastinal mass, and AW not such an issue now. Platelets are falling fast - 30K over 6hrs. Pent, sux, tube.
 

aredoubleyou

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Good comments all.

There were no problems lying flat, and we managed to get in contact with the OSH, which revealed that she'd had a CT scan. The mass was prevascular, with no airway compression. Further workup had been deferred until after she delivered, it was presumed a likely lymphoma based on syxs.

So after much consternation, we decided her airway was not likely to be an issue, though the film gave us a good scare at first. It was surprising that "anterior mediastinal mass" didn't raise any red flags for the OBs, and you'd think they would have known the history and workup well, but waddya gonna do.

We asked for repeat plts, they were 70K. OK for spinal given the rapidity of this change?
Hopefully the baby is doing ok while (I assume) your running around like a beheaded chicken trying to call OSH's, gather records, etc, etc to increase your attending's comfort level :)

Falling PLTs and a non-symptomatic mass = benefits outweigh risks for GETA
Falling PLTs and a symptomatic mass = spinal

On the subject of OB w/u, you've gotta understand that the OB's training in things not gyncologic or obstetric basically abruptly ends at medical school. Ask a med student about their concerns regarding surgery and mediastinal masses to get a feel for what your obstetric team is thinking of.
 

Planktonmd

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Falling platelets are a concern if you are going to place an epidural and leave it while the platelets continue to fall.
I don't see why "falling platelets" would be a problem for a one shot spinal as long as the number is still within your comfort zone.
 

urge

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Why is it that oncologists will tap anyone with 15k plt and we "need" a hearty number like 100k?
 

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That's obstetricians for you: everything that a patient comes in with MUST be related to their pregnancy. Otherwise its unimportant.
 

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If an anterior mediastinal mass was significant and causing some degree of airway compromise this woman would not have made it to term pregnancy.
In general the fear of anterior mediastinal masses is most of the times exaggerated, and even the ones with mild to moderate airway compromise can be mask ventilated without a problem.
This patient is having some decelerations and the OB wants to proceed with a c section, I would do a spinal anesthetic like every C section we do, if for some reason the spinal fails or we need to do a stat C section I will not hesitate to do RSI and intubate her like any other patient.
I'm nominating you for a NOBEL PEACE PRIZE, LIKE AL GORE'S.

This truly is more meaningful than his.
 

IlDestriero

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If an anterior mediastinal mass was significant and causing some degree of airway compromise this woman would not have made it to term pregnancy.
In general the fear of anterior mediastinal masses is most of the times exaggerated, and even the ones with mild to moderate airway compromise can be mask ventilated without a problem.
This patient is having some decelerations and the OB wants to proceed with a c section, I would do a spinal anesthetic like every C section we do, if for some reason the spinal fails or we need to do a stat C section I will not hesitate to do RSI and intubate her like any other patient.
Considering that she is having new symptoms, that I admit are likely preeclampsia, I would insist on a STAT portable CXR to confirm that the mass is not considerably larger before I drop the Pent, Sux, Tube bomb on her. I would get that before I did the spinal, just in case it fails. Some of these mediastinal masses can grow FAST, and that CXR is from a few weeks ago. Plenty of time to double, or more, in size. That headache and mild edema in her hands may be from compression of the SVC, etc. The OB would never even consider that possibility, so YOU'RE HER ONLY HOPE, Obi Wan.
 

Hawaiian Bruin

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So at the end of the day, we decided that the risk of managing the airway wasn't as high as we originally reflexively feared, and despite the evolving HELLP syndrome, we were still OK for a single shot spinal at 70K. So the case proceeded like any other c/s.

I thought it was an interesting case because it made us think about what we would have done if the two variables were on the sinister side of the spectrum- what if the mass was symptomatic and compressing the airway, and what if the plt count got down to 30 or 40K or something where even a single shot spinal would be medicolegally sketchy, regardless of what the heme-onc dudes are doing with their 20g Quincke needles. We came up with a hypothetical plan for that scenario, curious what others would do in that spot.
 

BruinGasDoc

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Why is it that oncologists will tap anyone with 15k plt and we "need" a hearty number like 100k?
So true... my wife is a heme-onc doctor and she is a lot less scared of thrombocytopenia for both surgery and neuraxial blocks than I am. 50K platelets is plenty according to her for major surgery or neuraxial blocks. She's not really worried about thrombocytopenia until it drops <10K platelets. Of course, having experienced a full blown epidural hematoma in a patient of mine leading to complete paraplegia and bowel/bladder dysfunction (which was fortunately diagnosed and treated with an emergent laminectomy before the 8 hour cutoff with almost complete resolution of symptoms) I am much more nervous about thrombocytopenia and spinals. I do think your cutoff will vary depending on how difficult you feel the patient's airway is.
 

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So at the end of the day, we decided that the risk of managing the airway wasn't as high as we originally reflexively feared, and despite the evolving HELLP syndrome, we were still OK for a single shot spinal at 70K. So the case proceeded like any other c/s.

I thought it was an interesting case because it made us think about what we would have done if the two variables were on the sinister side of the spectrum- what if the mass was symptomatic and compressing the airway, and what if the plt count got down to 30 or 40K or something where even a single shot spinal would be medicolegally sketchy, regardless of what the heme-onc dudes are doing with their 20g Quincke needles. We came up with a hypothetical plan for that scenario, curious what others would do in that spot.
play the percentages. give platelets to make yourself feel better, do the spinal, and have ENT/CT backup available as you see fit. If presented with both situations at the same time the chance of losing the airway (good chance if shes already symptomatic awake) is much greater than the chance of a significant epidural hematoma (a rare complication under any circumstance).