Any advice for Placenta Increta/Percreta case?

[BruinGasDoc]

Hi everyone..

Just looking for some advice on anesthesia management for placenta increta/percreta. I have a case coming up on Tuesday, 30 y/o F G3P2 s/p C/S x 2 who now has a placenta increta/percreta (confirmed by MRI) invading through the myometrium to the bladder (either adherent or possibly invading into the bladder). Fortunately the patient is thinnish (BMI 27) with no other PMH. The current OB plan is for IR IIAOBC followed by C/S&C-hyst.
Anyone have any experience with these kind of cases? How much blood should I prepare for this case? Would you do MAC/sedation for the IR part or how about spinal narcotics? I'm thinking GETA for the C/S, C-hysterectomy as there can be heavy bleeding and blood transfusions leading to respiratory compromise requiring an airway anyways. I'm also thinking about avoiding epidural because of the risk of DIC postop leading to an epidural hematoma (I have already experienced a case of epidural hematoma as a resident and would like to avoid a repeat experience). My plan for monitors are A-line, Cordis, and 2 large bore PIV's preinduction. Will then do a RSI with a Glidescope. Thanks in advance for any input with this case. I haven't had the fortune of doing a placenta accreta case before so would appreciate any advice.

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[urge]

Pent, sux, tube.


I would have at least 10 u PRBC. Institute the blood bank trauma protocol right away if you get in trouble. +/- on the Cordis. A couple 14/16 IVs should be a'right.

 

[jwk]

Hi everyone..

Just looking for some advice on anesthesia management for placenta increta/percreta. I have a case coming up on Tuesday, 30 y/o F G3P2 s/p C/S x 2 who now has a placenta increta/percreta (confirmed by MRI) invading through the myometrium to the bladder (either adherent or possibly invading into the bladder). Fortunately the patient is thinnish (BMI 27) with no other PMH. The current OB plan is for IR IIAOBC followed by C/S&C-hyst.
Anyone have any experience with these kind of cases? How much blood should I prepare for this case? Would you do MAC/sedation for the IR part or how about spinal narcotics? I'm thinking GETA for the C/S, C-hysterectomy as there can be heavy bleeding and blood transfusions leading to respiratory compromise requiring an airway anyways. I'm also thinking about avoiding epidural because of the risk of DIC postop leading to an epidural hematoma (I have already experienced a case of epidural hematoma as a resident and would like to avoid a repeat experience). My plan for monitors are A-line, Cordis, and 2 large bore PIV's preinduction. Will then do a RSI with a Glidescope. Thanks in advance for any input with this case. I haven't had the fortune of doing a placenta accreta case before so would appreciate any advice.

Do a quick search and you would find this thread from a while back:

http://more.studentdoctor.net/showthread.php?t=661420

Here was my response:

We do these quite frequently because of our large OB volume and we do TONS of repeat C-Sections, and as you know, the risk for abnormal placental implantations rises with each C-Section. I recently did three of these in less than a month. We are strictly private practice, no residents. BTW, these cases should not come as a big surprise, unless your practice has a large number of patients with poor pre-natal care. Most of ours are diagnosed ahead of time.

We now do almost all of these with GETA from the start. We've tried being optimistic and going with epidurals but invariably these patients end up being put to sleep anyway. I haven't seen anyone mention DIC and/or dilutional coagulopathies, but that's certainly reason enough not to do a neuraxial technique. A boggy uterus is pretty much a given with these cases anyway, so GA really isn't contraindicated.

Two big IV's are a must, and if you really think it's going to hit the fan, it sure is nice having that introducer in place pre-induction instead of trying to do it under the drapes after you've already stepped in it. We generally go without the a-line.

Don't even consider just a type and screen with these cases. We type and cross for at least 4-6 units, and make sure the blood bank has more typed blood, FFP, pooled platelets, and cryo readily available. I will not start the case unless at least 4 units of blood are in the OR in a cooler. We transfuse early, and as soon as we do, we order the FFP and platelets and stay at least 4 units ahead on crossmatching more blood. These cases bleed like stink. Assume they will, treat it early, and most do pretty well.

These are not one-person cases either. We will usually have at least two anesthesia providers in the room the entire time, and it's not uncommon to have one or two more if necessary.​

And another from DreamMachine:

I just did my first one of these as an attending.

I couldn't agree more with this post.

We went straight to general. The time from incision until the baby was out was only 2 minutes, but then **** hit the fan. 1% sevo for 2 minutes isn't a big deal for the baby. They ended up doing a hysterectomy, so a boggy uterus wasn't an issue for the mommy either. The bleeding came real quick though. That was definitely not the time to have a "to do list." It took enough hands just to check and hang blood and push drugs. It was easy with the lines and ETT already in. It would have been extremely hard to convert to general in this case. Having seen the case go this way, I'm not going to take my chances in the future.​

Here's the take-home message: These cases suck, and they suck almost immediately. Prepare for the worst, hope for the best. Don't know about the UA occlusion balloons - you obviously can't use them before the baby is out, and thinks go to pot almost immediately after delivery. If the placenta is invading organs outside the uterus, it's going to suck regardless. Big lines in, BLOOD IN ROOM BEFORE INCISION, transfuse early, replace clotting factors just as early, and GA all the way - don't mess with any type of regional IMHO.

 

[2ndyear]

Personally, I like GA provided the airway looks OK (and your patient sounds thin at least). I know...avoid GA at all costs... but if you think about it, what is the risk of losing the airway in a VERY controlled situation vs. a stat emergent mess? Nobody knows, but inducing GA in a controlled fashion on pregnant ladies is not as dangerous as preached in training.

Spinal possibly, but hypotension sucks and so does the sedation to the point of losing the airway anyways and a sometimes long procedure. Epidural is probably the right answer for the oral boards, just pull it in a few days. If it's the real deal she WILL get coagulopathic guaranteed. Same thing about mucho sedation being necessary. At least it won't wear off.

I like an a line, makes sense for this case. Usually don't put them in preinduction. Elective case, she'll be stable until the cutting starts. Of course the OB's will be in a big hurry so the evil gasses don't poison junior.

Access is access. Couple of 14 gauges in the AC's and go to town. Skip the IJ stick unless things get real bad. The good thing about these cases is the patient is EXTREMELY healthy usually. This ain't a liver transplant on a smoking cirrhotic in renal failure with pulmonary HTN. This is a young healthy female, possibly obese, but generally between 18-40. Now granted there will be a big bloodletting to come, but I've done several of these in private practice now and I'm always surprised with how well they actually do (and how much quicker they are compared to residency).

 

[hoyden]

Prepare for a bloodbath - like in a liver transplant case ( less time for preparation, though).

GETA for sure, couple of large-bore IVs, or introducer, I would put an a-line.
Tons of typed and crossed blood, FFP, platelets in the room. You will also need more anesthesia providers than yourself. And if it is at all possible - there should be experienced surgeons, not only OB/GYNs doing it.

Good luck with it.

 

[rsgillmd]

Hi everyone..

Just looking for some advice on anesthesia management for placenta increta/percreta. I have a case coming up on Tuesday, 30 y/o F G3P2 s/p C/S x 2 who now has a placenta increta/percreta (confirmed by MRI) invading through the myometrium to the bladder (either adherent or possibly invading into the bladder). Fortunately the patient is thinnish (BMI 27) with no other PMH. The current OB plan is for IR IIAOBC followed by C/S&C-hyst.
Anyone have any experience with these kind of cases? How much blood should I prepare for this case? Would you do MAC/sedation for the IR part or how about spinal narcotics? I'm thinking GETA for the C/S, C-hysterectomy as there can be heavy bleeding and blood transfusions leading to respiratory compromise requiring an airway anyways. I'm also thinking about avoiding epidural because of the risk of DIC postop leading to an epidural hematoma (I have already experienced a case of epidural hematoma as a resident and would like to avoid a repeat experience). My plan for monitors are A-line, Cordis, and 2 large bore PIV's preinduction. Will then do a RSI with a Glidescope. Thanks in advance for any input with this case. I haven't had the fortune of doing a placenta accreta case before so would appreciate any advice.

If the MRI is showing it invading to the bladder, just put her to sleep from the beginning. I've seen suspected accretas via MRI turn out not to be when opened, but when it is clearly invading all the way through you are guaranteed to be in for trouble.

The suspected ones, we would place large bore IVs (no less than a 16, usually 2 14s) and a CSE in the holding area and then send them to IR for their balloons. When they got back and into the OR, A-line (usually) and dose the epidural. Fluid warmers and Bair Hugger from the start. If they went to sleep, humidifier also. Obviously blood and products were available. How much varied according to the patient. Remember that there are a lot of collaterals to the uterus. In my experience the balloons are good at decreasing the bleeding, but they will not stop it. The nice thing about most pregnant patients (except where I work now) is that they are relatively healthy. They also have a greater blood volume than non-pregnant patients, even if it is relatively diluted. As such they can afford to lose more. We did 1:1 or 1:1.5 FFPRBC. This decreases the dilutional coagulopathy associated with massive transfusion.

I have done one case of accreta with balloons and bladder injury during surgery and massive transfusion under epidural. We were on top of the resuscitation so with her being non-English speaking she didn't realize anything was wrong. Later in the case she became uncomfortable, probably more from being supine for a long time, but this was easily managed with a little bit of midazolam. Epidural for post-op pain control. Pulled it the next day. If you do a search there are articles that describe success under neuraxial anesthesia alone (one of them is a review article). I just can't remember the journal/author of that review article at this time. However, I would not blame anyone for putting such patients to sleep, and especially the way you are describing your patient.

 

[BruinGasDoc]

Thank you all so much for the advice so far. So sounds like a couple of large bore IV's (14/16G) is sufficient for this percreta? If I can't get large bore IV's, going straight to a Cordis for IV access. My department originally wanted me to supervise this room along with 2 other OR's but I've negotiated it down to doing this case 1-to-1 with a CRNA. I don't think it's a good idea to leave a CRNA in this room as I'm preoping some other patient at any time during the procedure.

What are all of your thoughts on sedation for the IR part of the case? Would a low dose ketofol infusion be safe for mom/baby or would something like intrathecal fentanyl be preferable? Or should I just politely tell the mom to "suck it up" for the baby's sake?

I'm still not sure about the epidural as well. In addition to the risk of neuraxial hematoma, the sympathectomy may be really bad if the patient is in hemorrhagic shock.

Another issue I am considering is whether I should get Urology involved early as there is a real possibility of bladder/urinary tract injury with this situation.

Thank you all so much for your help. I just joined the website tonight after seeing a colleague reading it at work today. Still learning how to use the SDN features (such as the search function).

 

[jetproppilot]

Do a quick search and you would find this thread from a while back:

http://more.studentdoctor.net/showthread.php?t=661420

Here was my response:

We do these quite frequently because of our large OB volume and we do TONS of repeat C-Sections, and as you know, the risk for abnormal placental implantations rises with each C-Section. I recently did three of these in less than a month. We are strictly private practice, no residents. BTW, these cases should not come as a big surprise, unless your practice has a large number of patients with poor pre-natal care. Most of ours are diagnosed ahead of time.

We now do almost all of these with GETA from the start. We've tried being optimistic and going with epidurals but invariably these patients end up being put to sleep anyway. I haven't seen anyone mention DIC and/or dilutional coagulopathies, but that's certainly reason enough not to do a neuraxial technique. A boggy uterus is pretty much a given with these cases anyway, so GA really isn't contraindicated.

Two big IV's are a must, and if you really think it's going to hit the fan, it sure is nice having that introducer in place pre-induction instead of trying to do it under the drapes after you've already stepped in it. We generally go without the a-line.

Don't even consider just a type and screen with these cases. We type and cross for at least 4-6 units, and make sure the blood bank has more typed blood, FFP, pooled platelets, and cryo readily available. I will not start the case unless at least 4 units of blood are in the OR in a cooler. We transfuse early, and as soon as we do, we order the FFP and platelets and stay at least 4 units ahead on crossmatching more blood. These cases bleed like stink. Assume they will, treat it early, and most do pretty well.

These are not one-person cases either. We will usually have at least two anesthesia providers in the room the entire time, and it's not uncommon to have one or two more if necessary.​

And another from DreamMachine:

I just did my first one of these as an attending.

I couldn't agree more with this post.

We went straight to general. The time from incision until the baby was out was only 2 minutes, but then **** hit the fan. 1% sevo for 2 minutes isn't a big deal for the baby. They ended up doing a hysterectomy, so a boggy uterus wasn't an issue for the mommy either. The bleeding came real quick though. That was definitely not the time to have a "to do list." It took enough hands just to check and hang blood and push drugs. It was easy with the lines and ETT already in. It would have been extremely hard to convert to general in this case. Having seen the case go this way, I'm not going to take my chances in the future.​

Here's the take-home message: These cases suck, and they suck almost immediately. Prepare for the worst, hope for the best. Don't know about the UA occlusion balloons - you obviously can't use them before the baby is out, and thinks go to pot almost immediately after delivery. If the placenta is invading organs outside the uterus, it's going to suck regardless. Big lines in, BLOOD IN ROOM BEFORE INCISION, transfuse early, replace clotting factors just as early, and GA all the way - don't mess with any type of regional IMHO.

THIS JWK POST NEEDS TO MATRICULATE INTO THE BIBLE. NEW TESTAMENT, I GUESS. MARK, PSALM 33, VERSE 1,378: "HATH NO IRREVERENT ANESTHESIA DUDE ENTER INTO THE WRATH OF GOD WITHOUT A CUPPLA BIG IVs AND PLENTY OF BLOOD PRODUCTS, OR RISK BECOMING A PARIAH."

 

[drccw]

You can do almost any case with 2 big IVs (14G)
Central access (introducer) only if access is a problem.
A-linie is nice for drawing blood and for telling you exactly how hypotensive the patient is from beat to beat.. some people are fine just knowing the patient's pressure sucks every 5 minutes... And if this is a true increta, then that'll likely happen.....

IR for balloons is nice; but it can be a pain in the ass. Ie how to sedate the patient, moving the patient (can be a pain in the ass with catheters) and what the hell to do with the balloons if they are needed (and are they in the right place). A good surgeon should theoritcally be able to ligate many of the major arteries pretty darn quick. I have heard of cases of doing the entire procedure in IR with a hysterectomy setup (not all hospitals are equipped to do real cases in IR; I worked one place that an endo AAA became an open procedure..)

If the airway isnt a problem, then I would consider starting the case with a spinal if the patient really wants to be awake. If it's an increta, they at some point you can put the gal to sleep. If not, then everything is hunky dory. I'm not the touchy feely but chicks dig that whole being awake for the c/s thing.

Most importantly is support staff:
- have a real surgeon there. Whoever is the surgical stud at your hospital, have them either right outside or scrubbed. We usually get the bad mother Gyn Onc surgeon. Don't let OBs screw you.
- have the people to run blood from the blood bank. If the fan is hit, then you are going to need products, and a ton of them. I did one increta (unknown) and we sucked down a total about 40 units.
- have help on your end. 1:1 with a CRNA (hopefully capable) is important. More help may be needed. Rapid infusers (oh sweet belmont) are a big plus, but you need people to check blood and run them.
- have a real nurse in the room, not a L&D nurse. Oh and this should be the main OD....

If this is a real increta; it more like a ruptured AAA with incompentent surgeons. Liver txps dont usually bleed all at once like an increta. The best line I ever heard from a OB was from the increta I did
"we're getting a lot of bleeding down here, can you get her pressure down"

that was after ~30 minutes of aggressive resucitation with a BP that hovered between 50-60 systolic.. I told the OB "nope, you're just going to have to work with a BP of 80/40"

Good luck. I love this cases.

 

[rsgillmd]

Thank you all so much for the advice so far. So sounds like a couple of large bore IV's (14/16G) is sufficient for this percreta? If I can't get large bore IV's, going straight to a Cordis for IV access. My department originally wanted me to supervise this room along with 2 other OR's but I've negotiated it down to doing this case 1-to-1 with a CRNA. I don't think it's a good idea to leave a CRNA in this room as I'm preoping some other patient at any time during the procedure.

What are all of your thoughts on sedation for the IR part of the case? Would a low dose ketofol infusion be safe for mom/baby or would something like intrathecal fentanyl be preferable? Or should I just politely tell the mom to "suck it up" for the baby's sake?

I'm still not sure about the epidural as well. In addition to the risk of neuraxial hematoma, the sympathectomy may be really bad if the patient is in hemorrhagic shock.

Another issue I am considering is whether I should get Urology involved early as there is a real possibility of bladder/urinary tract injury with this situation.

Thank you all so much for your help. I just joined the website tonight after seeing a colleague reading it at work today. Still learning how to use the SDN features (such as the search function).

Welcome to the board. I like these types of cases because you get to see different styles/viewpoints.

I've told you my approach to the IR case CSE. You could probably even do a single shot spinal if you are really worried about the epidural. After all I never got called up to IR to dose the epidural. My CSE dose was Spinal: Bupivacaine 1.5 mg + Fentanyl 15 mcg, Epidural: Fentanyl 85 mcg. The patients got sent up immediately after placement of the CSE and were brought down by a member of the IR team. We didn't send anyone special to monitor these patients. If you want to do sedation there are probably a million and one recipes. However if you are going to do seadation in IR, then you should provide an anesthesiologist/CRNA to be with the patient.

Definitely these should be 1:1 at a minimum. We usually started these with 1 attending to 1 resident. For those cases where there was trouble we were always able to call in at least one other resident and another attending to help get through the crunch.

I agree with the individual that said to make sure you have people designated as runners, quality nurses, etc.

Definitely get urology on board early. I would ask for a senior urology resident to be in the room until the all clear has been sounded. The urology resident can assess the situation and call his attending if needed.

Another individual mentioned about a quality surgeon. That goes without saying. Our best surgeon was a GYN-Onc surgeon, and everyone knew it. Some of these cases were planned to be done around his availability.

Remember, if you are prepared everything will probably go smoothly. It's when you are not prepared that things go downhill very quickly. Good luck and let us know how it goes.

 

[proman]

If things get really out of hand you need to have 1) an aortic cross clamp on the table and 2) someone who knows how to use it (I've yet to meet a OBGYN who does).

 

[Idiopathic]

man to me a true percreta should get expeditious section followed by ligation of uterine vessels and hysterectomy. it just seems like a setup for disaster now or in the future, when essentially your uterus has failed you in such a way

 

[Noyac]

JWK touched on this. He mentioned that these cases always go to sleep. THis is academic dogma that I still abide by. I will agree that there may be a case or two that can get away with a regional technique but why try it. When the time comes and the pt starts getting the tunnel vision of hypotension I don't want to be trying to intubate through the emesis while I also need to be getting the BP up and starting the PRBC's.

 

[aredoubleyou]

Personally, I like GA provided the airway looks OK (and your patient sounds thin at least).

Actually, in my mind I would think exactly opposite...I'd only consider regional if the airway looked good. If it didnt look ok, then defenitely start with GA cause 99% of the time thats where the case is heading.

 

[fakin' the funk]

Just want to add that this thread is f#$king awesome, and I can't wait until CA-1 year starts. I've had it up to here with 90 year olds with pneumonia and heart failure during internship...

 

[BruinGasDoc]

Just want to add that this thread is f#$king awesome, and I can't wait until CA-1 year starts. I've had it up to here with 90 year olds with pneumonia and heart failure during internship...

Well.. after you join anesthesia.. you'll be anesthetizing those medical trainwrecks.. just a different set of challenges. Glad to see that you are enthusiastic about anesthesia though.

Thanks everyone for all of the advice for this case. I've talked to a bunch of anesthesiologists (colleagues at work, people I did residency with) and most have very limited or no experience (0-1 cases). I really appreciate all the input from all of you on the SDN forums.

I was just on call yesterday and happened to do a IR case for a spontaneous renal hemorrhage and had a chance to talk to the IR guys who feel no sedation should be needed for the placement of the balloons.

I talked to some OB attendings yesterday and the ones who have done percreta remember bad hemorrhage and at least 15-20 units of pRBC's transfused. For this case, I'm going to put in a Cordis hooked up to a Rapid Infuser, 2 large bore IV's, and arterial line (better to have too much access than too little in this case I feel) all preinduction and then go straight away with a RSI GETA with a Glidescope ready to go in case of difficult intubation. I feel that a PA Cath is overkill for this case.. anyone out there think otherwise? I'm going to avoid any spinal/epidural and use a PCA after to manage her pain (there's a good chance she'll go to the ICU intubated anyways...) Going to have 8 U PRBC, 8 U FFP, 2 pooled units of platelets in the OR immediately available. Anyone have any comments/further advice re: my plan? Thanks again for all the advice/support from all of you by the way.

 

[doctor712]

bruin,
eager to year how it turns out. Please be sure to post...
D712

 

[sevoflurane]

If there is a potential to give 5-15 units of blood... why do a neuraxial technique? Especially a spinal... it's like shooting yourself in the foot before incision IMHO. I understand mom would like to be awake for delivery of her new born, but some cases should be done asleep. I believe this to be one of them. I can see an argument for epidural, but as mentioned above, dilutional coagulopathy may keep you up wondering at night. Of course, you can pull it at the end of the case with a shot of duramorph and call it a day.
I would keep it simple with this case. Good access, blood/products in the room, a-line. Good surgery/staff support.

 

[rsgillmd]

.....Going to have 8 U PRBC, 8 U FFP, 2 pooled units of platelets in the OR immediately available. Anyone have any comments/further advice re: my plan? Thanks again for all the advice/support from all of you by the way.

Sounds like a good plan. Besides having urology on-board, make sure ICU team knows that you may be calling them for a bed. If they know ahead of time, they may be a little more likely to transfer out the borderline patients to stepdown or floor in order to have room for you. If they don't have room, you may get stuck with her in PACU.

Also remember that once you thaw FFP, you either give it or throw it away. Once I learned that I became a little more conservative about how much FFP I ordered ahead of time.

But you also have to take your blood bank into account. Where I trained: No problem starting FFP and calling blood bank to thaw more. They worked well with us. We also had a hemorrhage protocol in place there. Where I am now: hemorrhage protocol also exists, but turn around time is too slow for most general cases. I would rather waste it than not have it.

 

[BruinGasDoc]

We put in a RIJ Cordis, 18G and 16G PIV's, and a R radial A-line. I also put in intrathecal sufentanil/Duramorph. IR is working on placing the ureteral stents and the internal iliac artery balloon occlusion catheters now. The fun part is still to come... The GYN-ONC expert has done 4 percretas.. including one where he said it was attached to the bladder base and they needed to transfuse 81 units of pRBC's... hopefully this won't be one of those percretas. Thanks again to everyone for the support. Will keep you all posted on how it turns out.

 

[hoyden]

We put in a RIJ Cordis, 18G and 16G PIV's, and a R radial A-line. I also put in intrathecal sufentanil/Duramorph. IR is working on placing the ureteral stents and the internal iliac artery balloon occlusion catheters now. The fun part is still to come... The GYN-ONC expert has done 4 percretas.. including one where he said it was attached to the bladder base and they needed to transfuse 81 units of pRBC's... hopefully this won't be one of those percretas. Thanks again to everyone for the support. Will keep you all posted on how it turns out.

You will need urology on-board. Get it if you can and good luck.

 

[BruinGasDoc]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

 

[rsgillmd]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

Nice work. Glad everything went well.

Cesarean Hysterectomy I presume?

You said into the bladder. What did they do with it? Ileal conduit?

 

[urge]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

The balloon thing was a sham then?

Good job!

 

[IlDestriero]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

Better you than me!
Good job. Sounds like it was fun.
If you're looking at 26L of blood loss, I can't help but think that there must have been something else that they could have clamped off, including possibly the distal aorta, while they did some damage control. Who knows?
Another

 

[sevoflurane]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

Good job and thanks for posting your experience.
I don't think I have seen such blood loss during a complex OB/GYN case (including a couple of percreta's). I don't usually see that much with the livers I have done (there are exceptions).

 

[polkadotcap]

I did one of these this week, but mine was managed incredibly differently- we started with a CSE and 2 big IV's, they started with a cysto. Cysto revealed pulsating vessels on the bladder wall They then did a C/S, left placenta, sewed up the uterus, and shipped mom off to the antepartum floor for nonoperative management. We had belmont, lines, blood, the whole shebang ready to go during the C/S, but didn't need any of it since they left the placenta alone. She lost about 750, had no additional bleeding, and per the OB's she probably won't even end up going to IR for embolization, she may get methotrexate to help things along. They're going to wait a bit for it to involute and then come back for a hysterectomy. I thought it was an interesting management approach I was completely unfamiliar with, but seems to have worked extremely well thus far for this patient.

 

[rsgillmd]

I did one of these this week, but mine was managed incredibly differently- we started with a CSE and 2 big IV's, they started with a cysto. Cysto revealed pulsating vessels on the bladder wall They then did a C/S, left placenta, sewed up the uterus, and shipped mom off to the antepartum floor for nonoperative management. We had belmont, lines, blood, the whole shebang ready to go during the C/S, but didn't need any of it since they left the placenta alone. She lost about 750, had no additional bleeding, and per the OB's she probably won't even end up going to IR for embolization, she may get methotrexate to help things along. They're going to wait a bit for it to involute and then come back for a hysterectomy. I thought it was an interesting management approach I was completely unfamiliar with, but seems to have worked extremely well thus far for this patient.

Polkadotcap, write this up as a poster for a conference if you haven't done so already -- SOAP or ASA specifically come to mind. One of my colleagues during residency had a case managed similarly. I think it's a relatively recent thing leaving the placenta alone. So presenting you case would help increase the level of awareness. The deadline for SOAP has already passed, but ASA deadline isn't until May.

 

[hoyden]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

Great job! That blood loss is impressive.
Thanks for sharing the experience.

 

[Eta Carinae]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

OMG!

Cases like this make me salivate!! I CANNOT WAIT to get my hands on one of these darlings!!!

Oh but it's so close, I can almost taste it!!!! Closest I've come is a liver transplant for congenital hepatic fibrosis and worsening liver failure. SERIOUSLY that's like DeVito to this Arnold (although they did play twins in the movie, "twins")!!

Men, I can't wait!! I can feel the adrenaline already!

 

[Eta Carinae]

Well.. 26000 EBL later with 38 U pRBC, 39 U FFP, 7 U of pooled platelets, 10U of cryoprecipitate transfused with 11000 cc of crystalloid and a 1000 cc of Hextend given.. the surgeons are closing and we're getting ready to take the patient to the ICU intubated. This was a real percreta extended all the way into the bladder. We managed to get the INR back down to 1.2, PTT at 34, Fibrinogen over 200 and get the H/H to 8/25 (it had dropped to 5/15). Hopefully the patient does OK in the ICU. Thanks everyone for your advice.. it was definitely an interesting case. The Cordis + 2 large bore PIV's is definitely the way to go.. there were portions where we were running the Level 1 rapid infusor through the Cordis and pressure bagging pRBC's through both 16G PIV's. Calcium chloride is a must too as we had constant hypocalcemia. Don't mess with percreta.

OMG, though.

You like bankrupted the BB.

 

[jwk]

You will need urology on-board. Get it if you can and good luck.

This and the gyn-onc suggestion are VERY good ideas. Most OB docs (no offense intended) simply don't have the surgical chops to deal with this kind of blood loss. We frequently have one of our gyn-onc guys involved with these cases, and have also used general and vascular surgeons from time to time.

 

[doctor712]

This and the gyn-onc suggestion are VERY good ideas. Most OB docs (no offense intended) simply don't have the surgical chops to deal with this kind of blood loss. We frequently have one of our gyn-onc guys involved with these cases, and have also used general and vascular surgeons from time to time.

So, JWK, how does this happen in the real word? Or rather, how SHOULD it happen, for us neophytes, that is, getting a Gyn/Onc into the room with an OB/GYN when we feel it's necessary?

How are the politics played out in PP and Academia?

I could imagine that, perhaps, the OB/GYN might be rather pissed if he/she sees "another" surgeon in the room? Who makes the call here? Who would you initially approach? I imagine a few OB/GYNs are pretty picky about their own surgical chops and would really not be happy...

So, how to deal? That is, without pissing off an entire department or group?

D712

 

[jwk]

So, JWK, how does this happen in the real word? Or rather, how SHOULD it happen, for us neophytes, that is, getting a Gyn/Onc into the room with an OB/GYN when we feel it's necessary?

How are the politics played out in PP and Academia?

I could imagine that, perhaps, the OB/GYN might be rather pissed if he/she sees "another" surgeon in the room? Who makes the call here? Who would you initially approach? I imagine a few OB/GYNs are pretty picky about their own surgical chops and would really not be happy...

So, how to deal? That is, without pissing off an entire department or group?

D712

Our OB and Gyn/Onc guys have a very good working relationship, and many refer to them anyway for the bulk of their cancer-related GYN stuff. These really are 2+ doc cases. It's really no different than if they get into the bowel or bladder on a hysterectomy - they call in a general/colorectal surgeon or a urologist. Not a big deal, at least in my private practice world.

 

[OB1🤙]

I had a run a few months ago when I did 3 of these in two weeks, with different attendings and techniques.

Twice we did a CSE and converted to GA once the baby was out. We did an aline preSAB, had 2 good 16s for both. EBL about 3L for both, needed RBCs/FFP but no other coagulopathy developed. We used pressure bags and had a Level One on standby but it wasn't necessary.

The reasons for the CSEs were that the moms really wanted to be awake for the deliveries, and the degree of increta wasn't clear, so there was a chance we could do the cases under neuraxial block. The attendings did say that without a dedicated 2nd pair of hands, they'd have done GA right off the bat. I thought it was very sketchy to have catheters in place if massive bleeding/coagulopathy was a real risk, and if would have preferred a single shot spinal if keeping mom awake for delivery.

The 3rd one was a bad increta and we just intubated right away, again with an aline and 2 16s. The MFM OB took a look at things post-delivery, decided there was no way in hell the uterus wasn't coming out, closed the uterus with the placenta intact, and went straight to c-hys. I applauded his approach.

 

[BruinGasDoc]

Just went to check on the patient in the ICU today... was still intubated but seemed to be awake and neurologically intact and understood what I was telling her. The patient was not taken back in the middle of the night for a reop.


As for the case, after the IR procedure to place 2 IIAOBC's, we induced GA with a RSI. Patient had an easy airway fortunately... didn't even need the Glidescope. 2 Gyn-Onc attendings were there to start the case.. the primary OB was just assisting. They tried to dissect out the uterus initially to prepare for the hysterectomy and did this for about 40 minutes but got into "torrential bleeding" and decided to quick cut into the uterus to get the baby out. Despite the 40 minutes of GA, the baby was crying and deemed to be fine before being taken to the NICU. Meanwhile.. the bleeding continued and the resuscitation began. The surgeons had to hold manual pressure several times during more episodes of "torrential bleeding" (this is per the Gyn-Onc surgeon's operative note) during the case while we were catching up with resuscitation. They only inflated the IIAOBC's like 1 1/2 hours into the hysterectomy when the patient was getting hypotensive (SBP of 80's) despite blood product resuscitation through the Cordis (rapid infusor) and 2 16G PIV's with pressure bags. Apparently the IIAOBC is only effective for about 20 minutes before the bleeding just shifts to the collaterals. Anyways, the balloons allowed us to catch up with the resuscitation and the SBP never dropped again below the 100's. We kept checking labs Q1hour and followed a 6 pRBC:6 FFP:1 pooled platetets transfusion protocol while giving 10U cryo when the Fibrinogen was dropping to the low 100's. We also gave Calcium chloride for hypocalcemia and NaHCO3 to help with the metabolic acidosis. After the hysterectomy and RSO and placenta removal from the bladder, 2 urologists were called in to repair the Right ureter and the bladder. At the end of the case, the patient still had a slowly oozing retroperitoneal bleed that the Gyn-Oncs placed a pack for. By the end of the case, we had gotten to base deficit back to under 2 (it was up to around 9) with INR 1.1, PTT 31, Fibrinogen > 300 and a Hb of 11/Hct of 32.

I asked the primary Gyn-Onc attending about the conservative approach of leaving the placenta and uterus in place. He was aware of such cases in the literature but he also knew of conservatively managed cases that led to the patient crashing and that he was not comfortable with that approach. Also, another question I should have brought up was the use of Cell Saver for this case? I've heard somewhere that Cell Saver use is acceptable in caesarean hysterectomies as the cell saver is able to filter out the amniotic fluid components. Anyone know anything about this?

All in all, an interesting case that I was glad to be a part of (especially since the patient had a good outcome). Thanks to you all for your advice and support through the case. Looking forward to participating more in the SDN Anesthesia forums and chatting with all of you.

 

[BruinGasDoc]

This and the gyn-onc suggestion are VERY good ideas. Most OB docs (no offense intended) simply don't have the surgical chops to deal with this kind of blood loss. We frequently have one of our gyn-onc guys involved with these cases, and have also used general and vascular surgeons from time to time.

I definitely second getting Gyn-Onc and Urology as well as IR (in addition to Neonatalogy and Hematology) as I feel it takes a multidisciplinary approach (this is supported by most of the literature re: hysterectomy for percretas to the bladder) to effectively manage a severe percreta.

 

[jwk]

Also, another question I should have brought up was the use of Cell Saver for this case? I've heard somewhere that Cell Saver use is acceptable in caesarean hysterectomies as the cell saver is able to filter out the amniotic fluid components. Anyone know anything about this?

Cellsaver use is generally contraindicated with the presence of amniotic fluid due to complement activation. I'm aware of people using it on occasion after cesarean delivery, following liberal irrigation of the abdominal cavity to wash out as much amniotic fluid as possible. The filter in the cardiotomy reservoir probably won't do anything with the amniotic fluid, however what little amniotic fluid that might remain would be probably we washed out when the RBC's are washed prior to reinfusion. I'm not sure if any studies have been done with this, but most of the manufacturers of cellsaver devices would recommend against it's use in these situations.

And although cellsavers are superb for some situations, "torrential" blood loss scenarios have their own set of problems. Remember that what you get back from the cellsaver is simply RBC's in saline - no clotting factors, no platelets, no nothing. In massive transfusion cases, you wouldn't be relying on cellsaver alone, so you're going to be giving banked blood anyway, along with FFP, platelets, cryo, etc. At that point, it may be helpful as far as keeping up with just the red cell replacement, but you've lost any benefit from an autologous transfusion standpoint.