Case study: The interesting OB patient

[UTSouthwestern]

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One more to throw out:

27 year old hispanic female G9,P7,A1, 5'4, 245 presents at full term for repeat c/s X 5. Pfanninstiel incisions for all previous c sections done at a south Texas academic center. Previous transfusions for pregnancies 5 and 8 2/2 severe intraop blood loss with last c/s requiring conversion to GA and post op ICU admission for two days.

On this admission, history was given as the above plus DMII, HTN, environmental exposures when she was working as a migrant farmer in south Texas. (+) PPD. A(+) blood type. Hct 35, normal chem 7, other lab work otherwise unavailable/not drawn. Pt c/o difficulty swallowing after last admission to the ICU with vivid memories and fear of having an ET tube in place. Came to the OB clinic two days prior to the scheduled date of the c/s. No previous medical records available.

She is on the schedule for an elective c/s under probable combined spinal/epidural, but while waiting for two emergent c/s's to complete, has SROM and onset of labor. She becomes tachypneic and is witnessed by her family to have an episode of "shaking" before passing out then spontaneously reawakening without obvious sequelae. Fetal monitor shows possible late decels with fetal HR dropping to the 100's at 3 points.

Ecclampsia is the presumptive diagnosis by the senior OB resident and she wants to bring the patient to the OR immediately. Before going to the OR, her pressure is noted to be 95/43, HR 120's to 140's, some variable decels.

What would you do and why?

 

[Monty Python]

One more to throw out:

27 year old hispanic female G9,P7,A1, 5'4, 245 presents at full term for repeat c/s X 5. Pfanninstiel incisions for all previous c sections done at a south Texas academic center. Previous transfusions for pregnancies 5 and 8 2/2 severe intraop blood loss with last c/s requiring conversion to GA and post op ICU admission for two days.

On this admission, history was given as the above plus DMII, HTN, environmental exposures when she was working as a migrant farmer in south Texas. (+) PPD. A(+) blood type. Hct 35, normal chem 7, other lab work otherwise unavailable/not drawn. Pt c/o difficulty swallowing after last admission to the ICU with vivid memories and fear of having an ET tube in place.

She is on the schedule for an elective c/s under probable combined spinal/epidural, but while waiting for two emergent c/s's to complete, has SROM and onset of labor. She becomes tachypneic and is witnessed by her family to have an episode of "shaking" before passing out then spontaneously reawakening without obvious sequelae. Fetal monitor shows possible late decels with fetal HR dropping to the 100's at 3 points.

Ecclampsia is the presumptive diagnosis by the senior OB resident and she wants to bring the patient to the OR immediately. Before going to the OR, her pressure is noted to be 95/43, HR 120's to 140's, some variable decels.

What would you do and why?

Gee, sounds like a typical day when I was with the LSU/Charity Hospital system. Only, add another 100 pounds to the pt profile.

Assuming there's nothing frightening about her airway, and based on the OB resident's insistence for immediate c/section, I would go GA. You probably don't have enough time for an incrementally dosing an epidural to T-4 (assuming you get it in quickly) and with her BP already that low I'm not too comfortable with single-shot spinal. Besides, I was taught true eclampsia is a contraindication to SAB.

I'd take a moment to thoroughly explain the rationale to the pt and, based on previous recall of the ETT, give (maybe, perhaps) a little versed. This will, of course, annoy the pediatrician but they'll get over it. I'd also drop down to a 6.5 ETT with a 6.0 ready.

Another thing: if this is c/section number 7 to the 3rd power the OB will be looking at gobs of scar tissue. Bleeding will probably be impressive. If you're faced with the possibility (high probability) of intraoperative transfusion you're better off with a secured airway from the get-go. And if things get really hairy you can just give roc/vec, go light on the gas, and add more versed, essentially putting the pt on autopilot while you concern yourself with volume status and RBC issues.

Alert the blood bank right now. Have colloid in the OR. And a trauma pressure infusor. Find several free people to help put in 2 large bore IVs right now.

Looking at those vitals, has OB ruled out something sinister of recent onset with the placenta?

A little versed, pentothal/diprivan, sux, and titrate fent after the baby is out. You mentioned previous environmental exposure as a migrant farm worker. Don't overlook the probability of organophosphate-induced delayed recovery from the sux.

 

[Monty Python]

One more to throw out:

27 year old hispanic female G9,P7,A1, 5'4, 245 presents at full term for repeat c/s X 5. Pfanninstiel incisions for all previous c sections done at a south Texas academic center. Previous transfusions for pregnancies 5 and 8 2/2 severe intraop blood loss with last c/s requiring conversion to GA and post op ICU admission for two days.

On this admission, history was given as the above plus DMII, HTN, environmental exposures when she was working as a migrant farmer in south Texas. (+) PPD. A(+) blood type. Hct 35, normal chem 7, other lab work otherwise unavailable/not drawn. Pt c/o difficulty swallowing after last admission to the ICU with vivid memories and fear of having an ET tube in place.

She is on the schedule for an elective c/s under probable combined spinal/epidural, but while waiting for two emergent c/s's to complete, has SROM and onset of labor. She becomes tachypneic and is witnessed by her family to have an episode of "shaking" before passing out then spontaneously reawakening without obvious sequelae. Fetal monitor shows possible late decels with fetal HR dropping to the 100's at 3 points.

Ecclampsia is the presumptive diagnosis by the senior OB resident and she wants to bring the patient to the OR immediately. Before going to the OR, her pressure is noted to be 95/43, HR 120's to 140's, some variable decels.

What would you do and why?

Gee, sounds like a typical day when I was with the LSU/Charity Hospital system. Only, add another 100 pounds to the pt profile.

Assuming there's nothing frightening about her airway, and based on the OB resident's insistence for immediate c/section, I would go GA. You probably don't have enough time for an incrementally dosing an epidural to T-4 (assuming you get it in quickly) and with her BP already that low I'm not too comfortable with single-shot spinal. Besides, I was taught true eclampsia is a contraindication to SAB.

I'd take a moment to thoroughly explain the rationale to the pt and, based on previous recall of the ETT, give (maybe, perhaps) a little versed. This will, of course, annoy the pediatrician but they'll get over it. I'd also drop down to a 6.5 ETT with a 6.0 ready.

Another thing: if this is c/section number 7 to the 3rd power the OB will be looking at gobs of scar tissue. Bleeding will probably be impressive. If you're faced with the possibility (high probability) of intraoperative transfusion you're better off with a secured airway from the get-go. And if things get really hairy you can just give roc/vec, go light on the gas, and add more versed, essentially putting the pt on autopilot while you concern yourself with volume status and RBC issues.

Alert the blood bank right now. Have colloid in the OR. And a trauma pressure infusor. Find several free people to help put in 2 large bore IVs right now.

Looking at those vitals, has OB ruled out something sinister of recent onset with the placenta? Another reason to consider the probable need of intraop transfusion.

A little versed, pentothal/diprivan, sux, and titrate fent after the baby is out. You mentioned previous environmental exposure as a migrant farm worker. Don't overlook the probability of organophosphate-induced delayed recovery from the sux.

 

[jetproppilot]

One more to throw out:

27 year old hispanic female G9,P7,A1, 5'4, 245 presents at full term for repeat c/s X 5. Pfanninstiel incisions for all previous c sections done at a south Texas academic center. Previous transfusions for pregnancies 5 and 8 2/2 severe intraop blood loss with last c/s requiring conversion to GA and post op ICU admission for two days.

On this admission, history was given as the above plus DMII, HTN, environmental exposures when she was working as a migrant farmer in south Texas. (+) PPD. A(+) blood type. Hct 35, normal chem 7, other lab work otherwise unavailable/not drawn. Pt c/o difficulty swallowing after last admission to the ICU with vivid memories and fear of having an ET tube in place. Came to the OB clinic two days prior to the scheduled date of the c/s. No previous medical records available.

She is on the schedule for an elective c/s under probable combined spinal/epidural, but while waiting for two emergent c/s's to complete, has SROM and onset of labor. She becomes tachypneic and is witnessed by her family to have an episode of "shaking" before passing out then spontaneously reawakening without obvious sequelae. Fetal monitor shows possible late decels with fetal HR dropping to the 100's at 3 points.

Ecclampsia is the presumptive diagnosis by the senior OB resident and she wants to bring the patient to the OR immediately. Before going to the OR, her pressure is noted to be 95/43, HR 120's to 140's, some variable decels.

What would you do and why?

Seizures from eclampsia would involve a post-ictal state so I don't think she had a seizure. Plus she's HYPOtensive, not hyper...I don't agree with the dx.

Hypotension, tachycardia, and some sign of fetal distress make me think she has some type of antepartum hemorrhage....placenta previa? Uterine rupture?
I agree with the OB...to the OR, call the blood bank to get her typed and matched blood in the OR, if it is not available have O- in the vicinity, monitors on, pre O2, ketamine 1mg/kg, 160-200 mg sux, put the tube in! Sounds like intubation may be kinda fun...5'4" 245lbs....get ready for a volume/transfusion fest.

 

[Justin4563]

no chance of a regional.. none after so many c sections the rate of abnormal placentation is fairly high.. (increta, accreta, percreta)

preoxygenate generously

pent sux tube... aline (pre induction) .. large bore ivs for infusion.. blood.. Be prepared for massive transfusion.. and be ready for cesarian hysterectomy.. That is a bear of a case.. prob one of the worst in anesthesia the c-his.

Platelet problems, DIC AFE... nice stuff.. be prepared

 

[UTSouthwestern]

Seizures from eclampsia would involve a post-ictal state so I don't think she had a seizure. Plus she's HYPOtensive, not hyper...I don't agree with the dx.

Hypotension, tachycardia, and some sign of fetal distress make me think she has some type of antepartum hemorrhage....placenta previa? Uterine rupture?
I agree with the OB...to the OR, call the blood bank to get her typed and matched blood in the OR, if it is not available have O- in the vicinity, monitors on, pre O2, ketamine 1mg/kg, 160-200 mg sux, put the tube in! Sounds like intubation may be kinda fun...5'4" 245lbs....get ready for a volume/transfusion fest.

You're on the right track.

After careful consultation with the senior OB resident ("If you don't take her back now, I'm going to call a stat c/s!"), the anesthesia resident speaks to the patient and voices his desire to do a general anesthetic, along with all of its attendant risks and benefits, plus the risks and benefits of transfusion. The patient refuses a GA. While awaiting the return of the OB resident, the patient's V.S. continue to hover at BP 90-100 systolic with HR 110-120's baseline, 130's to 140's with contractions. She complains of terrific abdominal pain and shortness of breath. A repeat Hct shows 35. Fetal heart monitoring shows intermittent late decels not correlating with the mother's contractions.

The OB resident arrives and in a furious display of broken Spanish, tries to convince the patient to accept a GA. Patient still refuses and the resident asks us to proceed with a regional technique. Additional blood work has been sent off and urine has been sent from a freshly placed foley.

The patient is taken back to the OR and fetal monitors attached by the OR nurses (despite the official ASAP designation of this patient now). Monitors are placed (3 lead ECG) and oxygen by NC at 3 lpm given. After a generous preloading with about 750 cc's LR, a moderately complicated CSE is placed with the spinal dosed at 1 cc 0.375% bupi with 20 mcg fentanyl. The patient is layed supine with left uterine displacement and a block level of T6 achieved.

The patient notes complete relief of pain but remains tachypneic which she attributes to being nervous.

Urine studies come back with 1+ LE, no casts, no protein. Stat blood work is still cooking. 2 units of blood are en route.

The dissection to the uterus is fairly uncomplicated and a healthy looking 9.5 pound baby boy with APGARS 9,9 is delivered. Blood loss is attendant with the patient's previous surgical history and thus higher than normal (i.e. more than 1 liter). Uterine atony is adequately reversed with oxytocin.

The patient, however, is no longer conscious, is breathing with very short rapid gasps, and has a heart rate of 160.

What has happened and what would you do?

 

[Monty Python]

You're on the right track.

After careful consultation with the senior OB resident ("If you don't take her back now, I'm going to call a stat c/s!"), the anesthesia resident speaks to the patient and voices his desire to do a general anesthetic, along with all of its attendant risks and benefits, plus the risks and benefits of transfusion. The patient refuses a GA. While awaiting the return of the OB resident, the patient's V.S. continue to hover at BP 90-100 systolic with HR 110-120's baseline, 130's to 140's with contractions. She complains of terrific abdominal pain and shortness of breath. A repeat Hct shows 35. Fetal heart monitoring shows intermittent late decels not correlating with the mother's contractions.

The OB resident arrives and in a furious display of broken Spanish, tries to convince the patient to accept a GA. Patient still refuses and the resident asks us to proceed with a regional technique. Additional blood work has been sent off and urine has been sent from a freshly placed foley.

The patient is taken back to the OR and fetal monitors attached by the OR nurses (despite the official ASAP designation of this patient now). Monitors are placed (3 lead ECG) and oxygen by NC at 3 lpm given. After a generous preloading with about 750 cc's LR, a moderately complicated CSE is placed with the spinal dosed at 1 cc 0.375% bupi with 20 mcg fentanyl. The patient is layed supine with left uterine displacement and a block level of T6 achieved.

The patient notes complete relief of pain but remains tachypneic which she attributes to being nervous.

Urine studies come back with 1+ LE, no casts, no protein. Stat blood work is still cooking. 2 units of blood are en route.

The dissection to the uterus is fairly uncomplicated and a healthy looking 9.5 pound baby boy with APGARS 9,9 is delivered. Blood loss is attendant with the patient's previous surgical history and thus higher than normal (i.e. more than 1 liter). Uterine atony is adequately reversed with oxytocin.

The patient, however, is no longer conscious, is breathing with very short rapid gasps, and has a heart rate of 160.

What has happened and what would you do?

Perhaps far-fetched, but ....

In the opening thread, you said she was a repeat (ie, scheduled) c/section and was initially stable. The fun with her status started rapidly when she experienced SROM and has gone downhill. Did she have a partial amniotic fluid embolism?

You also gave her complaint of terrific abdominal pain. Did the OB fully explore the abdomen before closing? Is anything perfed, herniated, incarcerated up around the diaphragm?

 

[UTSouthwestern]

The clinical suspicion of AFE was ever present but that tends to be a diagnosis of exclusion. Bleeding was controlled and a senior OB staff member was present and ensured that nothing grossly abnormal was present. The abdomen was explored but no signs of hemorrhaging or infection was discovered.

By the way, this was an actual case.

After the patient crumps, the patient's sats began to drop into the 80's. HR remained tachy. The patient was masked with 100% O2 and her sats moved to the high 80's, but the patient remained unresponsive. The anesthesia resident attempted intubation with a MAC, Miller, and Phillips blade all without success. The patient vomited, but no solid particles, just brownish liquid that was quickly suctioned out of the OP.

The faculty for the case was finally able to drop an Eschmann stylet through the cords and a 6.5 ETT was threaded over the stylet. Confirmation of equal breath sounds was made.

Another resident had placed an A line and an 18 ga AC which we immediately wired for a RIC.

A warmer is hastily assembled and the two units of blood go in lickity split. Further surgical exploration reveals no intraabdominal pathology of significance. An ABG shows uncompensated respiratory acidosis with a base deficit of 8. The Hgb prior to transfusion of two units is 9.4.

What are your thought processes now and what would you do?

(Will conclude this later this evening)

 

[juddson]

This is a like a finely wrought Clancy novel.

continue. . .

 

[zippy2u]

Always keep (PTE) pulm.thrombo embolism at the top of the list in this case. Regards,--- Zippy

 

[jetproppilot]

You're on the right track.

After careful consultation with the senior OB resident ("If you don't take her back now, I'm going to call a stat c/s!"), the anesthesia resident speaks to the patient and voices his desire to do a general anesthetic, along with all of its attendant risks and benefits, plus the risks and benefits of transfusion. The patient refuses a GA. While awaiting the return of the OB resident, the patient's V.S. continue to hover at BP 90-100 systolic with HR 110-120's baseline, 130's to 140's with contractions. She complains of terrific abdominal pain and shortness of breath. A repeat Hct shows 35. Fetal heart monitoring shows intermittent late decels not correlating with the mother's contractions.

The OB resident arrives and in a furious display of broken Spanish, tries to convince the patient to accept a GA. Patient still refuses and the resident asks us to proceed with a regional technique. Additional blood work has been sent off and urine has been sent from a freshly placed foley.

The patient is taken back to the OR and fetal monitors attached by the OR nurses (despite the official ASAP designation of this patient now). Monitors are placed (3 lead ECG) and oxygen by NC at 3 lpm given. After a generous preloading with about 750 cc's LR, a moderately complicated CSE is placed with the spinal dosed at 1 cc 0.375% bupi with 20 mcg fentanyl. The patient is layed supine with left uterine displacement and a block level of T6 achieved.

The patient notes complete relief of pain but remains tachypneic which she attributes to being nervous.

Urine studies come back with 1+ LE, no casts, no protein. Stat blood work is still cooking. 2 units of blood are en route.

The dissection to the uterus is fairly uncomplicated and a healthy looking 9.5 pound baby boy with APGARS 9,9 is delivered. Blood loss is attendant with the patient's previous surgical history and thus higher than normal (i.e. more than 1 liter). Uterine atony is adequately reversed with oxytocin.

The patient, however, is no longer conscious, is breathing with very short rapid gasps, and has a heart rate of 160.

What has happened and what would you do?

amniotic fluid embolus with resultant intra-pulmonary shunt. She needs to be intubated, central line placed for pharmacologic hemodynamic support.

 

[zippy2u]

Also with teaching centers and residents involved beware of the high neuraxial block-- you don't always have to have bradycardia. --Zippy

 

[jetproppilot]

The clinical suspicion of AFE was ever present but that tends to be a diagnosis of exclusion. Bleeding was controlled and a senior OB staff member was present and ensured that nothing grossly abnormal was present. The abdomen was explored but no signs of hemorrhaging or infection was discovered.

By the way, this was an actual case.

After the patient crumps, the patient's sats began to drop into the 80's. HR remained tachy. The patient was masked with 100% O2 and her sats moved to the high 80's, but the patient remained unresponsive. The anesthesia resident attempted intubation with a MAC, Miller, and Phillips blade all without success. The patient vomited, but no solid particles, just brownish liquid that was quickly suctioned out of the OP.

The faculty for the case was finally able to drop an Eschmann stylet through the cords and a 6.5 ETT was threaded over the stylet. Confirmation of equal breath sounds was made.

Another resident had placed an A line and an 18 ga AC which we immediately wired for a RIC.

A warmer is hastily assembled and the two units of blood go in lickity split. Further surgical exploration reveals no intraabdominal pathology of significance. An ABG shows uncompensated respiratory acidosis with a base deficit of 8. The Hgb prior to transfusion of two units is 9.4.

What are your thought processes now and what would you do?

(Will conclude this later this evening)

Agressive ventilation with FiO2 1.0, dopamine at 5ug/kg/min and titrate to acceptable hemodynamics, suspect DIC so draw D-dimer, fibrinogen level, etc, redraw ABG to see if you are making any headway, NaHCO3 if indicated, type and match for FFP and platelets, definitely start a central line if you havent already since peripheral vasoconstriction will hamper peripherally-administered inotropes/vasopressors, consider a PAC to solve unsolved hemodynamic irregularities.

 

[jetproppilot]

One more to throw out:

27 year old hispanic female G9,P7,A1, 5'4, 245 presents at full term for repeat c/s X 5. Pfanninstiel incisions for all previous c sections done at a south Texas academic center. Previous transfusions for pregnancies 5 and 8 2/2 severe intraop blood loss with last c/s requiring conversion to GA and post op ICU admission for two days.

On this admission, history was given as the above plus DMII, HTN, environmental exposures when she was working as a migrant farmer in south Texas. (+) PPD. A(+) blood type. Hct 35, normal chem 7, other lab work otherwise unavailable/not drawn. Pt c/o difficulty swallowing after last admission to the ICU with vivid memories and fear of having an ET tube in place. Came to the OB clinic two days prior to the scheduled date of the c/s. No previous medical records available.

She is on the schedule for an elective c/s under probable combined spinal/epidural, but while waiting for two emergent c/s's to complete, has SROM and onset of labor. She becomes tachypneic and is witnessed by her family to have an episode of "shaking" before passing out then spontaneously reawakening without obvious sequelae. Fetal monitor shows possible late decels with fetal HR dropping to the 100's at 3 points.

Ecclampsia is the presumptive diagnosis by the senior OB resident and she wants to bring the patient to the OR immediately. Before going to the OR, her pressure is noted to be 95/43, HR 120's to 140's, some variable decels.

What would you do and why?

By the way, it's ironic how we in the medical profession get lulled into normalcy with the patients we see. 27 y/o G9 P7!!!!!!!!! Gimme a ***king break!!! I'd be hesitant to have that many kids on my income, and yet we treat these people day after day, week after week. I'm sure she's not insured. Her medical bill will defy logic, yet these unemployed/uneducated women (and the irresponsible men that insemminate them) continue to pop out poverty-stricken children. Sometimes after I put an epidural in a woman like that I think "am I doing the right thing?" Is my craft really contributing to society?

 

[redstorm]

hey jet ours is not to judge..... terrible thing to sit in judgement


why didnt you start off with a general anesthetic.. you could have predicted this was going to happen to the patient.. I assume to stay away from the airway.. On the boards this exact situation will happen.. You will put a spinal in and it will always be high and you will have to intubate.. Now what? She is difficult and now you have no time to "Numb her up" and do a fiberoptic.. I guess you have to keep coming up with options.. 1.mask ventilate... vomit...... tredelenburg.... suction... DL.. see nothing...... LMA.... more vomitus... Bradycardia... more bradycardia... call for trach.... ..Ob makes incision to save the baby.. more bradycardia.. what are you gonna do doc... ... CRICOthyrodotomy.. doesnt matter where.. 11 blade right at the membrane make a big hole and put a 5.5 ett in and ventilate.. ensure end tital co2.. heart rate comes up..... hopefully her brain is not mush....

this is the worst scenario.

so to avoid this I think bad airway.. c section i think you have to at least think awake fiber optic... if you dont do one.. come up with a plan to manage the airway emergently..

what a digression.. sorry

 

[UTSouthwestern]

OK, belly now full of Chinese food (mine, not the patient's).

After several rounds of neosynephrine, then a neo drip (was what was immediately available), the pressure rises to the 100's, but the rate remains high at 120-130. Sats on FiO2 of 100% rises to 91%. Repeat ABG shows improved respiratory acidosis with base deficit of 4, pH 7.27, Hgb 11.2. A Levophed infusion is started and has to be kept at 0.1 mcg/kg/min to keep the systolic pressures in the 100's.

With the assumption of AFE, the residents presumptively treat for AFE but continue to investigate other possibilities. In the meantime, the stat labs have finally been completed 30 minutes from the time they were drawn. Normal coags, normal LFT except for slightly above normal AST, A1C 6.4.

A central line is placed and vasoactives switched to the central line, infusion line remains with the RIC. Transduction of the central line shows CVP 29, enlarged a waves and very large v waves.

Peak airway pressures are 37 on a TV of 500 with the belly being closed rapidly by the senior resident.

What would you do now?

 

[UTSouthwestern]

hey jet ours is not to judge..... terrible thing to sit in judgement


why didnt you start off with a general anesthetic.. you could have predicted this was going to happen to the patient.. I assume to stay away from the airway.. On the boards this exact situation will happen.. You will put a spinal in and it will always be high and you will have to intubate.. Now what? She is difficult and now you have no time to "Numb her up" and do a fiberoptic.. I guess you have to keep coming up with options.. 1.mask ventilate... vomit...... tredelenburg.... suction... DL.. see nothing...... LMA.... more vomitus... Bradycardia... more bradycardia... call for trach.... ..Ob makes incision to save the baby.. more bradycardia.. what are you gonna do doc... ... CRICOthyrodotomy.. doesnt matter where.. 11 blade right at the membrane make a big hole and put a 5.5 ett in and ventilate.. ensure end tital co2.. heart rate comes up..... hopefully her brain is not mush....

this is the worst scenario.

so to avoid this I think bad airway.. c section i think you have to at least think awake fiber optic... if you dont do one.. come up with a plan to manage the airway emergently..

what a digression.. sorry

In this case, the patiently adamantly refused a GA despite our best efforts to convince her and the OB resident's attempt to brow beat her into agreeing.

 

[Justin4563]

UT

If she refused.. I would refuse to participate in the suicide. DId you get her permisiion when you ultimately put her to sleep when the **** hit the fan? In this situation the patient has no choice..absolutely none.. unless she signs a peice of paper that says its ok for you to kill me, i promise my next of kin wont sue you. This is another interesting thing.. does the patient decide what anesthetic you give.. you offer the patient an anesthetic and she accepts.. if you dont offer her an anesthetic she cant accept it.. so dont offer a regional... and thats odd anyway.. most people want to be put out...

 

[UTSouthwestern]

UT

If she refused.. I would refuse to participate in the suicide. DId you get her permisiion when you ultimately put her to sleep when the **** hit the fan? In this situation the patient has no choice..absolutely none.. unless she signs a peice of paper that says its ok for you to kill me, i promise my next of kin wont sue you. This is another interesting thing.. does the patient decide what anesthetic you give.. you offer the patient an anesthetic and she accepts.. if you dont offer her an anesthetic she cant accept it.. so dont offer a regional... and thats odd anyway.. most people want to be put out...

Would be nice to be able to just draw the line, but if you refuse to give an anesthetic and the baby and/or mother dies, you will still slide down the slippery slope. Also understand that I'm not the resident in this case, so I'm going by memory from my chief resident's review of interesting cases. What I gather from those involved is that all of the stuff going on is going on at a nearly frenetic pace.

 

[VentdependenT]

She make it off the vent?

 

[Monty Python]

Would be nice to be able to just draw the line, but if you refuse to give an anesthetic and the baby and/or mother dies, you will still slide down the slippery slope..........

I would respectfully disagree. If you outline for a patient what you consider to be the appropriate way to administer an anesthetic and they adamently refuse, you can then refuse to further participate in their care. You cannot be bullied into administering what you consider to be an inappropriate or inferior anesthetic simply due to pt demand/refusal. You as a professional practitioner have the right to remove yourself from the patient relationship, especially seeing as how the OB has not actually declared this to be an emergent/stat C/sec.

Had it been formally declared emergent, then you would be covered for intubation from the outset, despite pt complaint. Lacking an emergent declaration, you can disengage yourself from the relationship with no liability.

 

[militarymd]

OK, belly now full of Chinese food (mine, not the patient's).

After several rounds of neosynephrine, then a neo drip (was what was immediately available), the pressure rises to the 100's, but the rate remains high at 120-130. Sats on FiO2 of 100% rises to 91%. Repeat ABG shows improved respiratory acidosis with base deficit of 4, pH 7.27, Hgb 11.2. A Levophed infusion is started and has to be kept at 0.1 mcg/kg/min to keep the systolic pressures in the 100's.

In the meantime, the stat labs have finally been completed 30 minutes from the time they were drawn. Normal coags, normal LFT except for slightly above normal AST, A1C 6.4.

A central line is placed and vasoactives switched to the central line, infusion line remains with the RIC. Transduction of the central line shows CVP 29, enlarged a waves and very large v waves.

Peak airway pressures are 37 on a TV of 500 with the belly being closed rapidly by the senior resident.

What would you do now?

If this was AFE, it would be an unusual case based on normal coags. The cases that I have seen all had significant abnormalities in Coags.

In light of significantly abnormal filling pressures and wave forms, I would place a TEE or perform a fast TTE to visually evaluate the heart...looking for restrictive/constrictive abnormalities, myocardial failure, valve pathology, papillary muscle dysfunction, etc.

Pulmonary status: Run down the cockpit drills that should be second nature for us to evaluate the lungs....tube position, listen, make sure it is not kinked, or plugged, etc....checking for pneumo, mainstem, bronchospasm, etc.

 

[jetproppilot]

OK, belly now full of Chinese food (mine, not the patient's).

After several rounds of neosynephrine, then a neo drip (was what was immediately available), the pressure rises to the 100's, but the rate remains high at 120-130. Sats on FiO2 of 100% rises to 91%. Repeat ABG shows improved respiratory acidosis with base deficit of 4, pH 7.27, Hgb 11.2. A Levophed infusion is started and has to be kept at 0.1 mcg/kg/min to keep the systolic pressures in the 100's.

With the assumption of AFE, the residents presumptively treat for AFE but continue to investigate other possibilities. In the meantime, the stat labs have finally been completed 30 minutes from the time they were drawn. Normal coags, normal LFT except for slightly above normal AST, A1C 6.4.

A central line is placed and vasoactives switched to the central line, infusion line remains with the RIC. Transduction of the central line shows CVP 29, enlarged a waves and very large v waves.

Peak airway pressures are 37 on a TV of 500 with the belly being closed rapidly by the senior resident.

What would you do now?

She is at high risk of developing all the bad stuff that results from whatever shock syndrome...cardiac failure, pulmonary edema, ARDS, renal failure, hepatic failure, etc. Sounds like shes got pulmonary sequalae already (pulmonary edema and probably developing ARDS) so beware of right heart failure.
I would definitely put in a SWAN now. I would suspect her numbers to look something like:

1) CO= 12, CI= 4, high output failure
2) PAP= 60/40 from the embolic phenomena and resultant pulmonary edema/ARDS/impending right heart failure
3)PCWP= 30...see 2)
4)SVR 200-400
5)SVO2= 40s


It'd be cool to put down a TEE in the ICU to see if I could see the AFE and to see how her cardio-pulmonary echo looks, particularly her RV and pulmonary vessels.
She needs supportive care now- consider different ventilatory modes to maintain Pa02 around 60mmHg with as little barotrauma as possible, if you're at a big academic center consider nitric oxide for pulmonary hypertension, judicious fluid management to maintain at least an oliguric urine output, may need dopamine at renal dose, optimize Hb and CO to optimize SVO2, provided inotropic infusions as needed (i.e. leave-em-dead, I mean Levophed, or whatever else is appropriate), frequent labs to catch any developing DIC/hepatic syndromes.
Consider corticosteroids, yeah the literature poo-poos their efficacy but I saw 2 ARDS cases improve after corticosteroid Tx when I was an intern. Figure it cant hurt at this point.

 

[jetproppilot]

She is at high risk of developing all the bad stuff that results from whatever shock syndrome...cardiac failure, pulmonary edema, ARDS, renal failure, hepatic failure, etc. Sounds like shes got pulmonary sequalae already (pulmonary edema and probably developing ARDS) so beware of right heart failure.
I would definitely put in a SWAN now. I would suspect her numbers to look something like:

1) CO= 12, CI= 4, high output failure
2) PAP= 60/40 from the embolic phenomena and resultant pulmonary edema/ARDS/impending right heart failure
3)PCWP= 30...see 2)
4)SVR 200-400
5)SVO2= 40s


It'd be cool to put down a TEE in the ICU to see if I could see the AFE and to see how her cardio-pulmonary echo looks, particularly her RV and pulmonary vessels.
She needs supportive care now- consider different ventilatory modes to maintain Pa02 around 60mmHg with as little barotrauma as possible, if you're at a big academic center consider nitric oxide for pulmonary hypertension, judicious fluid management to maintain at least an oliguric urine output, may need dopamine at renal dose, optimize Hb and CO to optimize SVO2, provided inotropic infusions as needed (i.e. leave-em-dead, I mean Levophed, or whatever else is appropriate), frequent labs to catch any developing DIC/hepatic syndromes.
Consider corticosteroids, yeah the literature poo-poos their efficacy but I saw 2 ARDS cases improve after corticosteroid Tx when I was an intern. Figure it cant hurt at this point.

OH, and the most important thing, I'D BE ON THE PHONE WITH MILITARY SINCE HE's THE CRITICAL CARE MASTA BLASTA!!!
HEY CHI! HIT THE MICROPHONE AND SHOW US WHATCHA GOT!!!

 

[jetproppilot]

OH, and the most important thing, I'D BE ON THE PHONE WITH MILITARY SINCE HE's THE CRITICAL CARE MASTA BLASTA!!!
HEY CHI! HIT THE MICROPHONE AND SHOW US WHATCHA GOT!!!

And here is Military at the bedside:

"Ms. Smith, I am Asian Critical Care Masta. I have you cured in fifteen minute."

 

[militarymd]

And here is Military at the bedside:

"Ms. Smith, I am Asian Critical Care Masta. I have you cured in fifteen minute."

No, no....not quite Masta yet....so I say "I cure you in 30 minutes" 🙂

 

[militarymd]

I saw 2 ARDS cases improve after corticosteroid Tx when I was an intern. Figure it cant hurt at this point.

ARDS Network does recommend use of corticosteroids in Lung injury...Meduri data.

 

[UTSouthwestern]

Military nailed it. This was PPCM (peripartum cardiomyopathy). A TTE was done postoperatively and showed a globally dilated heart with estimated EF of 20-25%, dilated mitral and tricuspid annuli, PHTN with mean pressures 20's-30's, and significant WMA in the LAD and circ distribution. An inodilator and dobutamine were initiated and the patient was volume off loaded with multiple rounds of lasix. Rate control was established for what was determined to be both supply and demand ischemia and the patient was later catheterized but without stent placement or significant angioplasty done.

In our interview with the resident of this case and in our review of the preop, a physical exam failed to lead to a suspicion of heart failure because the patient had noted a 50 pound weight gain, shortness of breath, and leg swelling, all of which were within her norms for the previous pregnancies. Auscultation of the lung fields was made difficult by the patient's inability/refusal to inspire deeply and while a murmur was heard, it was equally difficult to qualify with the patient's body habitus and the resident's relative inexperience in discerning heart sound pathology. A preop ECG or CXR would have likely discovered her condition, but neither were going to be done in this ASAP/STAT situation.

She was extubated 4 days later with long term care assigned to cardiology. A week later, she was brought back to the ICU with acute chest pain syndrome which resolved with changes in her medication regimen. She was discharged home 2 weeks later and 4 months later, repeat TTE's showed improved global function with an EF of 35%, decreased ventricular and atrial dimensions, persistent but improved PHTN, and only mild MR and AR. She was told that any further pregnancies would likely reestablish the PPCM and likely lead to her death or need for an OHT.

One month after that, she thankfully got a BTL under spinal.

With regards to refusing to do the anesthesia, that is entirely acceptable in private practice, but as a resident, you don't have that leeway. The junior resident on the team initially refused to be involved with the regional but was told that he had no choice in the matter and would be subject to disciplinary actions if he refused. He relented and a review of this case by myself and co-chief led to a formal review with the education committee and the equivalent of a commendation for the resident for showing sound judgement and fundamentals.

 

[Zeffer]

Great case!!!! Didn't suspect the actual dx until you said elevated CVP with giant a-waves and normal coags. Then I so desprately wanted a cxr or preop ECG.

 

[toughlife]

UT

If she refused.. I would refuse to participate in the suicide. DId you get her permisiion when you ultimately put her to sleep when the **** hit the fan? In this situation the patient has no choice..absolutely none.. unless she signs a peice of paper that says its ok for you to kill me, i promise my next of kin wont sue you. This is another interesting thing.. does the patient decide what anesthetic you give.. you offer the patient an anesthetic and she accepts.. if you dont offer her an anesthetic she cant accept it.. so dont offer a regional... and thats odd anyway.. most people want to be put out...

I am hispanic so I can shed some light on this woman's refusal to receive GA. In latin america, it is common for people going under the knife to be afraid of general anesthetics for fear that they "won't wake up". They are not afraid of the surgery itself but, because medical care is not as good as it is here, they often hear of patients not waking up from their surgery and they attribute it to the anesthetic due to ignorance.

I usually approach hispanic patients in two different ways. First, I ask if they are US-born or if they were born in latin american. Why? Well, in latin america (at least where I come from) physicians tell patients what to do and never bother to ask whether the patient is ok with the plan they propose.

Latin american physicians are paternalistic and authoritarian and what they say goes. In other words, they are king in the hospital. No one, except another physician will challenge them. Patients that come from LA countries already know this and some already expect it. So when dealing with LA-born patients, I just tell them "this is what needs to be done and you need to sign here". I am fluent in Spanish so for me it works very well.

If they are US born, then they are used to the ways things are done here and you may not be able to do the above.


As far as jetprop pilot comments, I say that he has a point. Many hispanics that come to the US, (myself included), come here to work and have basic to no education at all when they arrive (of course, there are some that are highly educated). If we were all educated, we would not be doing the ****ty jobs we do, (farmworkers, housekeeping, etc).

Having a large family is largely excepted. On top of that, you have the catholic church telling you it is wrong to use birth control methods. Put those two together, and you have the perfect recipe for patients like the woman mentioned in this case.

If hispanics made it a point to have only two kids per family, we would not have the poverty we see in latin america and you would possible avoid cases like the patient mentioned here.

I am very self-critical so I apologize to any other frijo-vato out there who is offended by my comments.

peace,

 

[Gator05]

Toughlife,

Easy on the Catholic Church. Large families have their place, and the Church works pretty hard in these parts to help any family it can regardless of, well, pretty much anything.

That said, I appreciate the lesson on how Latin American countries approach medical decision making.

 

[toughlife]

Toughlife,

Easy on the Catholic Church. Large families have their place, and the Church works pretty hard in these parts to help any family it can regardless of, well, pretty much anything.

That said, I appreciate the lesson on how Latin American countries approach medical decision making.

No worries. I was born in raised catholic and continue to be, but I must admit that in latin america pushing the idea of not using birth control does not help when the per capita income is $2500 as opposed to $40K like in the USA.

 

[jetproppilot]

I am hispanic so I can shed some light on this woman's refusal to receive GA. In latin america, it is common for people going under the knife to be afraid of general anesthetics for fear that they "won't wake up". They are not afraid of the surgery itself but, because medical care is not as good as it is here, they often hear of patients not waking up from their surgery and they attribute it to the anesthetic due to ignorance.

I usually approach hispanic patients in two different ways. First, I ask if they are US-born or if they were born in latin american. Why? Well, in latin america (at least where I come from) physicians tell patients what to do and never bother to ask whether the patient is ok with the plan they propose.

Latin american physicians are paternalistic and authoritarian and what they say goes. In other words, they are king in the hospital. No one, except another physician will challenge them. Patients that come from LA countries already know this and some already expect it. So when dealing with LA-born patients, I just tell them "this is what needs to be done and you need to sign here". I am fluent in Spanish so for me it works very well.

If they are US born, then they are used to the ways things are done here and you may not be able to do the above.


As far as jetprop pilot comments, I say that he has a point. Many hispanics that come to the US, (myself included), come here to work and have basic to no education at all when they arrive (of course, there are some that are highly educated). If we were all educated, we would not be doing the ****ty jobs we do, (farmworkers, housekeeping, etc).

Having a large family is largely excepted. On top of that, you have the catholic church telling you it is wrong to use birth control methods. Put those two together, and you have the perfect recipe for patients like the woman mentioned in this case.

If hispanics made it a point to have only two kids per family, we would not have the poverty we see in latin america and you would possible avoid cases like the patient mentioned here.

I am very self-critical so I apologize to any other frijo-vato out there who is offended by my comments.

peace,

NIce post, Tough.
I am Catholic and see your point in the above reference. I am not always in agreement with their views. I think the Catholic church however, in their reference to birth control, is in reference to married couples since they frown on sex outside of marriage. How many 25 year old women presenting to the hospital for the birth of their, say, fifth-to-eighth child, had all of them from the same man?

 

[toughlife]

NIce post, Tough.
I am Catholic and see your point in the above reference. I am not always in agreement with their views. I think the Catholic church however, in their reference to birth control, is in reference to married couples since they frown on sex outside of marriage. How many 25 year old women presenting to the hospital for the birth of their, say, fifth-to-eighth child, had all of them from the same man?

True. The catholic church does tell you that you are to abstain from "getting it on" outside of marriage. The problem with hispanics is that many remember the "don't use contraceptives" part and choose to forget the abstinence part. Selective memory at work.

Also because of the high prevalence of illiteracy in farm workers, many women can't even read, let alone follow instructions on how to use birth control. I had a chance to work with farmworkers who don't even speak Spanish but Nahuatl which a dialect that's native to the Aztec/Mayan Indians of southern mexico and Western Guatemala. Imagine trying to explain how to use birth control to someone like that. You have also have men who think they are too macho (read as too stupid) to use condoms.

When rotating through peds, I had a patient who was a farmworker whose newborn had been admitted to the NICU for TTN. I spent some time talking to her and she told me that farms are like meatmarkets. Since much of the work is seasonal, many of the workers get to work in several farms during the year and that increases their chances of hooking up with other farmworkers leading to multiple pregnancies. When this woman told me that already had 4 kids in her native country, I told her she needed to get a TL.
I called OB and volunteered to serve as the interpreter and got her set up with the TL. I feel that was a good service to avoid this vicious cycle of multiple pregnancies and never-ending poverty that plagues hispanics.

 

[jetproppilot]

True. The catholic church does tell you that you are to abstain from "getting it on" outside of marriage. The problem with hispanics is that many remember the "don't use contraceptives" part and choose to forget the abstinence part. Selective memory at work.

Also because of the high prevalence of illiteracy in farm workers, many women can't even read, let alone follow instructions on how to use birth control. I had a chance to work with farmworkers who don't even speak Spanish but Nahuatl which a dialect that's native to the Aztec/Mayan Indians of southern mexico and Western Guatemala. Imagine trying to explain how to use birth control to someone like that. You have also have men who think they are too macho (read as too stupid) to use condoms.

When rotating through peds, I had a patient who was a farmworker whose newborn had been admitted to the NICU for TTN. I spent some time talking to her and she told me that farms are like meatmarkets. Since much of the work is seasonal, many of the workers get to work in several farms during the year and that increases their chances of hooking up with other farmworkers leading to multiple pregnancies. When this woman told me that already had 4 kids in her native country, I told her she needed to get a TL.
I called OB and volunteered to serve as the interpreter and got her set up with the TL. I feel that was a good service to avoid this vicious cycle of multiple pregnancies and never-ending poverty that plagues hispanics.

Nice work. 👍