#Case_06 was it aortocaval compression?

[DrAmir0078]

Dear SDN Anesthesiologists

I hope you are doing well, bringing up a case for discussion.

Yesterday we had an interesting case for C/S - elective, she was prepared, fasting time roughly over 8 hours, patient is young, and once she laid supine, her pulse rate was exceeding 150 bpm, and sometime reached 170 bpm. Very vague, isn't it? Aside from being covid positive! BP 130/80 like normal!

Well, we were skeptical between to proceed with neuraxial vs GA, we decided to do ECG, appears sinus tachycardia only.

Two days ago, we were having a discussion about aortocaval compression, and one of the methods especially used for CPR in pregnants, are to do either one hand or two hand left side tilt of abdomen, it helps in CPR. Actually, I requested from our primary PGY1 residents to aid the discussion, and interestingly one of the residents shows us a picture of the procedure, which is very interesting. (one hand vs two hands)

Back to the patient, while she was supine, I tried to do two hands pressure towards the left side, and what was amazingly happened, is that her pulse rate dropped to 135 bpm!

I freed my hand, the Tachycardia increased between 150 to 160 bpm.

We weren't sure, why? Our Attending was at the bedside instructing us, and then we put (pint of fluid - no wedge pillow available) underneath the right iliac crest to create left tilting, but wasn't that much successful to reduce the heart rate even with plus bed tilting, unless I put my both hands again, the pulse dramatically dropped to 130s bpm. Then we assumed it is an aortocaval compression, but why normotensive? It should've be hypotension, sweating,,, etc isn't it? Patient wasn't even anxious.

We ask the patient to sit, like we are trying to do spinal, her pulse rate dropped to 130s, once she was back supine, it increased very fast to 165 bpm!

I kept my hands on again and dropped to 130s not even 140s, then we decided GA, and another PGY1 started her induction smoothly, and with scoline - RSI, once scoline in, I felt my push was much better and stronger to get PR of 120 bpm, and she tubed the patient with ease!

The OBGYNs residents c/s her fast, reached the baby, but it was obstructed too, they got the help of their Senior, and I removed the pint of normal saline from underneath the patient, and once the baby out crying to life, we got a PR fixed on 135 bpm, and the patient didn't go hypotensive at all or hypoxic, except lax uterus and we managed it by decreasing the isoflurane + giving oxytocine, and the tachycardia kept interestingly at 130s bpm, from then I decided to load her with a third pint of fluid and a fourth one, and what we noticed her dry lips and mucosa (tongue adhered with the lower lip and have to separate them and see if she was dehydrated and yes, she was indeed) - she was waking up frequently and managed by muscle relaxant and covered with analgesia, and our discussion with Attending, we suggested this patient was dehydrated - not well prepared, as in our practice at the ICU, we saw lots of patients with hypertension relieved by hydrating the patient with crystaloid - Physiology is remarkable.

We tried to reduce more the heart rate by administration of 0.2 mg of metoprolol every like 5 minutes to check response, and it was really helpful to reduce the heart rate to less than the ischemic threshold of 120 bpm.

Patient smoothly extubated on PSVPro and put her for 10 minutes on simple face mask, then was sent to the ward with SPO2 of 98% room air and pulse rate less than 100 !

Me, and the first PGY1 (discussion circle two days ago - I called her and told her that our discussion probably makes a difference today) and we agreed to monitor every next case of CS and to do this two hands technique to see, is it actually reduce the heart rate? If so, this will be another option, as I am thinking loudly to use it often to ensure good flow both at aotric vs inferior vena cava.

This is the picture of one hand vs two hand left tilting of the uterus.
Thanks to this PGY1, she saved a patient on her off day with her knowledge I learned from her from our discussion.

Thanks for reading!

I am open to learning as you know me, I hope that this will bring additional knowledge!

Best,
Sincerely,
Dr Amir Al Shimmarii

P. S. Quoted from one of the textbook:

During CPR; to improve the quality left uterine displacement is advocated to remove the aorto-caval compression. This is done manually by 1-hand or 2-hand technique or by using a wedge of predetermined angle.

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[2Fast2Des]

An elective C\S with that level tachycardia, despite anxiety or youth, should have been a bit more optimized. I would think if the patient was this behind in volume she may have had some sign of visual dehydration. Fetal heart rate before hand? If you guys were doing all these manuevers to assess for aortocaval compression, and concerned for volume status, I would have just loaded her up and assessed with fluid challenge. I am not sure why you still did a GA, for tachycardia? I would have still done a spinal with phenylephrine in hand ruling out any significant issues. Beta-blockade.. ehh. Redosing Muscle relaxant for a C\S? Not necessary

 

[DrAmir0078]

An elective C\S with that level tachycardia, despite anxiety or youth, should have been a bit more optimized. I would think if the patient was this behind in volume she may have had some sign of visual dehydration. Fetal heart rate before hand? If you guys were doing all these manuevers to assess for aortocaval compression, and concerned for volume status, I would have just loaded her up and assessed with fluid challenge. I am not sure why you still did a GA, for tachycardia? I would have still done a spinal with phenylephrine in hand ruling out any significant issues. Beta-blockade.. ehh. Redosing Muscle relaxant for a C\S? Not necessary

Yup, although she was negative past medical history and you are right, and actually I loaded her with one 1 IV fluid from the beginning, it should've two - rapid and assess!
Well, honestly phenylephrine wasn't handy at all !
I honestly feard of spinal anesthesia + aortocaval would provoke hypotension, am I right and such tachycardia was a concern !
When I put my hands on the abdomen, I was able to feel the bounding like pulsation of the aorta, and her wrist pulse was also hyperdynamic aka water hummer pulse!
Yup, agree - no need for muscle relaxant, only analgesics, but we gave her only paracetamol + nefopam, we didn't have opioids. I understand, and wouldn't like to give her blouses of ketamine, because of her tachycardia (inappropriate excuse I admit).
Thanks for your feedback, but did you agree, it was aortocaval? Do you recommend to establish this procedure as a technique or making a paper study like?
Many Thanks

 

[deleted697127]

Yup, although she was negative past medical history and you are right, and actually I loaded her with one 1 IV fluid from the beginning, it should've two - rapid and assess!
Well, honestly phenylephrine wasn't handy at all !
I honestly feard of spinal anesthesia + aortocaval would provoke hypotension, am I right and such tachycardia was a concern !
When I put my hands on the abdomen, I was able to feel the bounding like pulsation of the aorta, and her wrist pulse was also hyperdynamic aka water hummer pulse!
Yup, agree - no need for muscle relaxant, only analgesics, but we gave her only paracetamol + nefopam, we didn't have opioids. I understand, and wouldn't like to give her blouses of ketamine, because of her tachycardia (inappropriate excuse I admit).
Thanks for your feedback, but did you agree, it was aortocaval? Do you recommend to establish this procedure as a technique or making a paper study like?
Many Thanks

Your hospital doesn’t have phenylephrine readily available? Seems almost like not having propofol available.

 

[DrAmir0078]

Your hospital doesn’t have phenylephrine readily available? Seems almost like not having propofol available.

Do not tell anyone please, I am from rich Country called Iraq, we don't have phenylephrine, the directorate of health won't supply us, we have shortage of medicine, sometime we buy it on our own at our own risk.
But I assure you, we have propofol at least to give credits to my honest, non corrupt government,,, etc
Please don't tell this secret, if they hear it, they will give thousands of excuses, one of them "Anesthesiologists didn't ask for it, or ask for it, but supply less, Santa Claus stole them,,, etc"

 

[deleted697127]

Do not tell anyone please, I am from rich Country called Iraq, we don't have phenylephrine, the directorate of health won't supply us, we have shortage of medicine, sometime we buy it on our own at our own risk.
But I assure you, we have propofol at least to give credits to my honest, non corrupt government,,, etc
Please don't tell this secret, if they hear it, they will give thousands of excuses, one of them "Anesthesiologists didn't ask for it, or ask for it, but supply less, Santa Claus stole them,,, etc"

Man. Makes me feel guilty about trashing over 50% of a 10mg vial whenever i do use it.

 

[DrAmir0078]

Man. Makes me feel guilty about trashing over 50% of a 10mg vial whenever i do use it.

Please wire it to Iraq lol ... We can buy it here, but even hard to get sometimes!
It is what it is!

 

[DrAmir0078]

Today, I had similar case, but base PR 125, with two hands left tilt, PR dropped to 110 - we tubed her and interestingly after delivery of the baby - the PR was 74 bpm!

Please try it out and what do you think?

Dear SDN Anesthesiologist

I hope you are doing well, bringing up a case for discussion.

Yesterday we had an interesting case for C/S - elective, she was prepared, fasting time roughly over 8 hours, patient is young, and once she laid supine, her pulse rate was exceeding 150 bpm, and sometime reached 170 bpm. Very vague, isn't it? Aside from being covid positive! BP 130/80 like normal!

Well, we were skeptical between to proceed with neuraxial vs GA, we decided to do ECG, appears sinus tachycardia only.

Two days ago, we were having a discussion about aortocaval compression, and one of the methods especially used for CPR in pregnants, are to do either one hand or two hand left side tilt of abdomen, it helps in CPR. Actually, I requested from our primary PGY1 residents to aid the discussion, and interestingly one of the residents shows us a picture of the procedure, which is very interesting. (one hand vs two hands)

Back to the patient, while she was supine, I tried to do two hands pressure towards the left side, and what was amazingly happened, is that her pulse rate dropped to 135 bpm!

I freed my hand, the Tachycardia increased between 150 to 160 bpm.

We weren't sure, why? Our Attending was at the bedside instructing us, and then we put (pint of fluid - no wedge pillow available) underneath the right iliac crest to create left tilting, but wasn't that much successful to reduce the heart rate even with plus bed tilting, unless I put my both hands again, the pulse dramatically dropped to 130s bpm. Then we assumed it is an aortocaval compression, but why normotensive? It should've be hypotension, sweating,,, etc isn't it? Patient wasn't even anxious.

We ask the patient to sit, like we are trying to do spinal, her pulse rate dropped to 130s, once she was back supine, it increased very fast to 165 bpm!

I kept my hands on again and dropped to 130s not even 140s, then we decided GA, and another PGY1 started her induction smoothly, and with scoline - RSI, once scoline in, I felt my push was much better and stronger to get PR of 120 bpm, and she tubed the patient with ease!

The OBGYNs residents c/s her fast, reached the baby, but it was obstructed too, they got the help of their Senior, and I removed the pint of normal saline from underneath the patient, and once the baby out crying to life, we got a PR fixed on 135 bpm, and the patient didn't go hypotensive at all or hypoxic, except lax uterus and we managed it by decreasing the isoflurane + giving oxytocine, and the tachycardia kept interestingly at 130s bpm, from then I decided to load her with a third pint of fluid and a fourth one, and what we noticed her dry lips and mucosa (tongue adhered with the lower lip and have to separate them and see if she was dehydrated and yes, she was indeed) - she was waking up frequently and managed by muscle relaxant and covered with analgesia, and our discussion with Attending, we suggested this patient was dehydrated - not well prepared, as in our practice at the ICU, we saw lots of patients with hypertension relieved by hydrating the patient with crystaloid - Physiology is remarkable.

We tried to reduce more the heart rate by administration of 0.2 mg of metoprolol every like 5 minutes to check response, and it was really helpful to reduce the heart rate to less than the ischemic threshold of 120 bpm.

Patient smoothly extubated on PSVPro and put her for 10 minutes on simple face mask, then was sent to the ward with SPO2 of 98% room air and pulse rate less than 100 !

Me, and the first PGY1 (discussion circle two days ago - I called her and told her that our discussion probably makes a difference today) and we agreed to monitor every next case of CS and to do this two hands technique to see, is it actually reduce the heart rate? If so, this will be another option, as I am thinking loudly to use it often to ensure good flow both at aotric vs inferior vena cava.

This is the picture of one hand vs two hand left tilting of the uterus.
Thanks to this PGY1, she saved a patient on her off day with her knowledge I learned from her from our discussion.

Thanks for reading!

I am open to learning as you know me, I hope that this will bring additional knowledge!

Best,
Sincerely,
Dr Amir Al Shimmarii

P. S. Quoted from one of the textbook:

During CPR; to improve the quality left uterine displacement is advocated to remove the aorto-caval compression. This is done manually by 1-hand or 2-hand technique or by using a wedge of predetermined angle.View attachment 333171

 

[abolt18]

Dear SDN Anesthesiologist

I hope you are doing well, bringing up a case for discussion.

Yesterday we had an interesting case for C/S - elective, she was prepared, fasting time roughly over 8 hours, patient is young, and once she laid supine, her pulse rate was exceeding 150 bpm, and sometime reached 170 bpm. Very vague, isn't it? Aside from being covid positive! BP 130/80 like normal!

Well, we were skeptical between to proceed with neuraxial vs GA, we decided to do ECG, appears sinus tachycardia only.

Two days ago, we were having a discussion about aortocaval compression, and one of the methods especially used for CPR in pregnants, are to do either one hand or two hand left side tilt of abdomen, it helps in CPR. Actually, I requested from our primary PGY1 residents to aid the discussion, and interestingly one of the residents shows us a picture of the procedure, which is very interesting. (one hand vs two hands)

Back to the patient, while she was supine, I tried to do two hands pressure towards the left side, and what was amazingly happened, is that her pulse rate dropped to 135 bpm!

I freed my hand, the Tachycardia increased between 150 to 160 bpm.

We weren't sure, why? Our Attending was at the bedside instructing us, and then we put (pint of fluid - no wedge pillow available) underneath the right iliac crest to create left tilting, but wasn't that much successful to reduce the heart rate even with plus bed tilting, unless I put my both hands again, the pulse dramatically dropped to 130s bpm. Then we assumed it is an aortocaval compression, but why normotensive? It should've be hypotension, sweating,,, etc isn't it? Patient wasn't even anxious.

We ask the patient to sit, like we are trying to do spinal, her pulse rate dropped to 130s, once she was back supine, it increased very fast to 165 bpm!

I kept my hands on again and dropped to 130s not even 140s, then we decided GA, and another PGY1 started her induction smoothly, and with scoline - RSI, once scoline in, I felt my push was much better and stronger to get PR of 120 bpm, and she tubed the patient with ease!

The OBGYNs residents c/s her fast, reached the baby, but it was obstructed too, they got the help of their Senior, and I removed the pint of normal saline from underneath the patient, and once the baby out crying to life, we got a PR fixed on 135 bpm, and the patient didn't go hypotensive at all or hypoxic, except lax uterus and we managed it by decreasing the isoflurane + giving oxytocine, and the tachycardia kept interestingly at 130s bpm, from then I decided to load her with a third pint of fluid and a fourth one, and what we noticed her dry lips and mucosa (tongue adhered with the lower lip and have to separate them and see if she was dehydrated and yes, she was indeed) - she was waking up frequently and managed by muscle relaxant and covered with analgesia, and our discussion with Attending, we suggested this patient was dehydrated - not well prepared, as in our practice at the ICU, we saw lots of patients with hypertension relieved by hydrating the patient with crystaloid - Physiology is remarkable.

We tried to reduce more the heart rate by administration of 0.2 mg of metoprolol every like 5 minutes to check response, and it was really helpful to reduce the heart rate to less than the ischemic threshold of 120 bpm.

Patient smoothly extubated on PSVPro and put her for 10 minutes on simple face mask, then was sent to the ward with SPO2 of 98% room air and pulse rate less than 100 !

Me, and the first PGY1 (discussion circle two days ago - I called her and told her that our discussion probably makes a difference today) and we agreed to monitor every next case of CS and to do this two hands technique to see, is it actually reduce the heart rate? If so, this will be another option, as I am thinking loudly to use it often to ensure good flow both at aotric vs inferior vena cava.

This is the picture of one hand vs two hand left tilting of the uterus.
Thanks to this PGY1, she saved a patient on her off day with her knowledge I learned from her from our discussion.

Thanks for reading!

I am open to learning as you know me, I hope that this will bring additional knowledge!

Best,
Sincerely,
Dr Amir Al Shimmarii

P. S. Quoted from one of the textbook:

During CPR; to improve the quality left uterine displacement is advocated to remove the aorto-caval compression. This is done manually by 1-hand or 2-hand technique or by using a wedge of predetermined angle.View attachment 333171

I do agree that this is secondary to what is likely caval compression. What I don't understand is why that would lead to a general anesthetic. She obviously had to be supine for the general anesthetic, so she'll do the same for a spinal.

If you really need, you could have the obstetricians, in their sterile gown and gloves, push on the abdomen after they prep until drapes are up and they've started. Either way, the treatment for this is getting that baby out, so do the spinal and tell them they need to move fast! Just like under the GA, things should get better after the baby is out.

And I agree, you need SOMETHING to support the blood pressure. 2 liters of fluid would not be a bad idea on someone who has such significant tachycardia related to caval compression. But if you have norepinephrine or even ephedrine, you can temporize the blood pressure until the baby is out.

 

[MirrorTodd]

I do agree that this is secondary to what is likely caval compression. What I don't understand is why that would lead to a general anesthetic. She obviously had to be supine for the general anesthetic, so she'll do the same for a spinal.

If you really need, you could have the obstetricians, in their sterile gown and gloves, push on the abdomen after they prep until drapes are up and they've started. Either way, the treatment for this is getting that baby out, so do the spinal and tell them they need to move fast! Just like under the GA, things should get better after the baby is out.

And I agree, you need SOMETHING to support the blood pressure. 2 liters of fluid would not be a bad idea on someone who has such significant tachycardia related to caval compression. But if you have norepinephrine or even ephedrine, you can temporize the blood pressure until the baby is out.

I was gonna suggest IM ephedrine, but understand that they are worried about the tachycardia.

 

[DrAmir0078]

I do agree that this is secondary to what is likely caval compression. What I don't understand is why that would lead to a general anesthetic. She obviously had to be supine for the general anesthetic, so she'll do the same for a spinal.

If you really need, you could have the obstetricians, in their sterile gown and gloves, push on the abdomen after they prep until drapes are up and they've started. Either way, the treatment for this is getting that baby out, so do the spinal and tell them they need to move fast! Just like under the GA, things should get better after the baby is out.

And I agree, you need SOMETHING to support the blood pressure. 2 liters of fluid would not be a bad idea on someone who has such significant tachycardia related to caval compression. But if you have norepinephrine or even ephedrine, you can temporize the blood pressure until the baby is out.

From my understanding and per Oxford I believe, every C/S is spinal until prove otherwise.
Yup, we've could do spinal, but no phenylephrine around, but I believe we have ephedrine handy. Yes, treatment of dehydration is mandatory here and no harm on AC issue. Many thanks!

 

[deleted697127]

I was gonna suggest IM ephedrine, but understand that they are worried about the tachycardia.

Phenylephrine is like $5 per 10mg vial. Ephedrine is $40 for 50mg vial

 

[DrAmir0078]

Yes we were worried about tachycardia, Ephedrine would shoot the HR.
But since I could get it to 130s, I believe if you agree giving metoprolol won't be a bad idea? This is the only Beta Blocker handy!
But if spinal, the issue of sympatheticomy, this will decrease the HR rapidly, and would jeopardize the uterine blood flow!. We can give atropine, yes in this case, but managing these issues without knowing the source and treating the cause!
Am I right?

I was gonna suggest IM ephedrine, but understand that they are worried about the tachycardia.

 

[DrAmir0078]

Phenylephrine is like $5 per 10mg vial. Ephedrine is $40 for 50mg vial

I am a buyer lol

 

[deleted162650]

I don't think ephedrine is going to make the tachycardia any worse if they're already 130+. It sounds to me like these patients are coming in dry as a bone, and desperately need some IV hydration before proceeding with any anesthetic.

Do you routinely place the table in Left Uterine Displacement position (15 degrees left tilt) so you don't have to manually displace the uterus?

 

[UnbentLaryngoscope]

If vasopressors (phenylephrine, etc.) are not readily available, another approach could be to do the c/s with an epidural. Place an epidural catheter, dose it slowly with local anesthetic, so that the minimum amount can be used to get the level required, thereby minimizing the associated sympathectomy and hypotension. Just a thought.

I would not give a beta blocker to this patient, she needed volume. This sinus tachycardia is a reflex physiologic response to poor venous return, from caval compression, in a patient that was probably starting out dehydrated. The other question in my mind is, did she have good prenatal care? Was she starting out anemic?

 

[DrAmir0078]

I don't think ephedrine is going to make the tachycardia any worse if they're already 130+. It sounds to me like these patients are coming in dry as a bone, and desperately need some IV hydration before proceeding with any anesthetic.

Do you routinely place the table in Left Uterine Displacement position (15 degrees left tilt) so you don't have to manually displace the uterus?

Hi Dr. SaltyDog,
That looks a good point, Ephedrine won't make it worse more than 130s, as she is!
Well, yes we do bed titling and 15 degree wedge (but we don't have the pillow as I mentioned we put a hard plastic IV bag underneath the right iliac crest), but was not helpful to be honest. We know the 15 degree angle.
But OBs have limited knowledge about it, is it the same with you guys?

 

[deleted162650]

But OBs have limited knowledge about it, is it the same with you guys?

Our OB's are fully aware of LUD. Despite that, they will sometimes ask us to level the bed. I'm happy to oblige as long as hemodynamics are unaffected.

 

[nimbus]

Do you have norepinephrine or vasopressin?

 

[DrAmir0078]

If vasopressors (phenylephrine, etc.) are not readily available, another approach could be to do the c/s with an epidural. Place an epidural catheter, dose it slowly with local anesthetic, so that the minimum amount can be used to get the level required, thereby minimizing the associated sympathectomy and hypotension. Just a thought.

I would not give a beta blocker to this patient, she needed volume. This sinus tachycardia is a reflex physiologic response to poor venous return, from caval compression, in a patient that was probably starting out dehydrated. The other question in my mind is, did she have good prenatal care? Was she starting out anemic?

That would be a good idea to me, but epidurals in Iraq is not always available, imagine till now and I am third, had done only 5 epidurals, but major training centers they have, even this, but convincing OBs is problematic to be honest!

Well good point, not to give metoprolol, but you have seen me giving small doses every 5 minutes with on-going fluid therapy.

Best

 

[DrAmir0078]

Do you have norepinephrine or vasopressin?

Hi Dr nimbus,
Nope, only at ICU or we supply our carrying anesthesia bag with it (buying on our own or having it from ICU), but that time nope!
Vassopressin! Only in books!

 

[DrAmir0078]

Our OB's are fully aware of LUD. Despite that, they will sometimes ask us to level the bed. I'm happy to oblige as long as hemodynamics are unaffected.

Today, I was explaining to OBs residents as like yesterday about it, with pictures too, and even spoke with an Academic Assistant professor OBs, she was aware of the two hands in CPR!
But I did prove to her the decrease in HR and then reached 74 bpm in the second case and although got a BP 96/74 mmgh but was easily manageable!

 

[deleted162650]

@DrAmir0078

I find many of your posts fascinating regarding the limitations in meds/equipment you have to work around (we take so much for granted here in the US).

Perhaps this is really best served with a new thread, but I am very curious to hear how things are today (healthcare wise), compared to how they were pre-invasion when Saddam was still in power. Your country has endured so much over these last 20 years.

 

[abolt18]

That would be a good idea to me, but epidurals in Iraq is not always available, imagine till now and I am third, had done only 5 epidurals, but major training centers they have, even this, but convincing OBs is problematic to be honest!

Well good point, not to give metoprolol, but you have seen me giving small doses every 5 minutes with on-going fluid therapy.

Best

The tachycardia is not the problem. It is only the sign of a problem (hypovolemia). I definitively would not be giving beta blocker to an otherwise healthy parturient in this scenario UNLESS we have made good efforts to correct the real problem: baby out, adequately fluid resuscitated, transfused blood if anemic.

 

[DrAmir0078]

@DrAmir0078

I find many of your posts fascinating regarding the limitations in meds/equipment you have to work around (we take so much for granted here in the US).

Perhaps this is really best served with a new thread, but I am very curious to hear how things are today (healthcare wise), compared to how they were pre-invasion when Saddam was still in power. Your country has endured so much over these last 20 years.

Thanks Dr. SaltyDog,
I and now third and from 2018 with my posts with you Anesthesiologists at SDN have grown up and you guys raised me up more in the knowledge of Anesthesia, your care, understanding my situation makes me feel this is my true avenue to vent and learn the best from the best, regardless of who you are, your positions (probably and imagining you guys are textbooks' editors), that is why I feel safe here and better safe future Anesthesiologist I hope!

Honestly, in the 70s and 80s era, Iraq was the top of the Middle East in medicine and Healthcare. We were the first in kidney transplant in a private hospital - Imagine not even governmental hospital!
The Medicine was having a special self pride, prestigious, strong, ethically motivated and more!

In the 90s, because of the Sanctions, we had suffered a lot, but still the major things I mentioned kept strong until the 1993, we fall down with medicines and equipment, no maintenance, but anesthesia was amazingly strong though, our Professors many of them passed unfortunately - their words like a knife cut, strong to control the theater, but then because of the income, private hospitals grown up, made the surgeon to manipulate how much the Anesthesiologist can get.

After the fall of Saddam, we were exhausted, lots of things happened, civil sectarian war, terrorism attacks, lots of things, those took a lot from our resources and since 2014, we became almost bankrupt and everything start to get limitations, but advanced facilities kept growing CT, MRI, scopes, and lots of things, even anesthesia some VL in teaching center in Baghdad, advanced techniques in airways... Etc

But, our pride is on the edge because of those weak personalities we have who are in power and some of them follow the political parties and lots of corruption.

Can I tell you, one Anesthesiologist asks for 7 USD in regard of his work in a private hospital for a cholecystectomy? The surgeon asks for like 800 USD and those weak oriented Anesthesiologists destroyed the practice unfortunately.

I am with hope, I want to make some change, I will try my best to build my knowledge and make it better, safe practice. I don't want the pride to eat me from inside and make me haughty or snobby one, will try to be modest, so I can help myself seeing the full picture!


Thanks a lot Dr. SaltyDog.

 

[DrAmir0078]

The tachycardia is not the problem. It is only the sign of a problem (hypovolemia). I definitively would not be giving beta blocker to an otherwise healthy parturient in this scenario UNLESS we have made good efforts to correct the real problem: baby out, adequately fluid resuscitated, transfused blood if anemic.

I'll stick with that advice!

I am so thankful...

 

[abolt18]

Our OB's are fully aware of LUD. Despite that, they will sometimes ask us to level the bed. I'm happy to oblige as long as hemodynamics are unaffected.

We have mostly stopped doing the bed tilt.

"Effect of Lateral Tilt Angle on the Volume of the Abdominal Aorta and Inferior Vena Cava in Pregnant and Nonpregnant Women Determined by Magnetic Resonance Imaging | Anesthesiology | American Society of Anesthesiologists" Effect of Lateral Tilt Angle on the Volume of the Abdominal Aorta and Inferior Vena Cava in Pregnant and Nonpregnant Women Determined by Magnetic Resonance Imaging | Anesthesiology | American Society of Anesthesiologists

TLDR: you need to tilt the bed ~30° to get any effective reduction in caval compression. Aka, drop the patient on the floor.

 

[DrAmir0078]

We have mostly stopped doing the bed tilt.

"Effect of Lateral Tilt Angle on the Volume of the Abdominal Aorta and Inferior Vena Cava in Pregnant and Nonpregnant Women Determined by Magnetic Resonance Imaging | Anesthesiology | American Society of Anesthesiologists" Effect of Lateral Tilt Angle on the Volume of the Abdominal Aorta and Inferior Vena Cava in Pregnant and Nonpregnant Women Determined by Magnetic Resonance Imaging | Anesthesiology | American Society of Anesthesiologists

TLDR: you need to tilt the bed ~30° to get any effective reduction in caval compression. Aka, drop the patient on the floor.

How about side rails up - I've never seen OR table with side rails!

We can make it 30 degree, but also need more creative ways like holding the patient to the table with restraints or blocking the hips down with special cover on the top and the chest too to prevent fall!

Will read the article!

Many Thanks

 

[abolt18]

How about side rails up - I've never seen OR table with side rails!

We can make it 30 degree, but also need more creative ways like holding the patient to the table with restraints or blocking the hips down with special cover on the top and the chest too to prevent fall!

Will read the article!

Many Thanks

Sorry, the point of it was that it's not reasonable to tilt the bed that far, and therefore there is no need to tilt the bed at all.

 

[deleted162650]

Sorry, the point of it was that it's not reasonable to tilt the bed that far, and therefore there is no need to tilt the bed at all.

Not true. It’s worth it just to irritate the OB’s.

 

[drmwvr]

Yesterday we had an interesting case for C/S - elective, she was prepared, fasting time roughly over 8 hours, patient is young, and once she laid supine, her pulse rate was exceeding 150 bpm, and sometime reached 170 bpm. Very vague, isn't it? Aside from being covid positive! BP 130/80 like normal!

caution for covid mediated myocarditis/pericarditis?

 

[DrAmir0078]

Sorry, the point of it was that it's not reasonable to tilt the bed that far, and therefore there is no need to tilt the bed at all.

So I need to work on a paper on that by using two hands uterine - abdominal displacement like and check every patient for effectiveness of dropping the HR!!!

 

[DrAmir0078]

caution for covid mediated myocarditis/pericarditis?

Yes Indeed, we had one patient passed covid +ve after giving her spinal unfortunately, most likely PE !
I am a bit aware of Myocarditis vs Pericarditis of covid patients, but how could you diagnose it?

 

[DrAmir0078]

@SaltyDog
I DM you for what a project I am going to do, so it will add extra to my statement above !

 

[DrAmir0078]

So, I just made a google form if you would like to participate in the study, I make two, one for me and my colleagues, the other one is for international participants, if you can fill it, to check the response, I am sure you are better than us in documenting, so it will be easy - but if you don't mind try to make the push on the uterus remarkable and check for the response ! !
It might work, It might not .... if you want to add extra points, I am happy to add !

Good Luck

Two Hands Technique to Reduce HR in a suspected Aortocaval Compression parturients undergoing C/S

This form is designated to be filled by Participant Residents (Qualified to this paper) in order to check the response of the technique. Presented by Anesthesia and Intensive Care Residents / Iraqi Board : Dr. Amir Al Shimmarii PGY3 aka CA2 KITC / Baghdad / Iraq

bit.ly

 

[drmwvr]

Yes Indeed, we had one patient passed covid +ve after giving her spinal unfortunately, most likely PE !
I am a bit aware of Myocarditis vs Pericarditis of covid patients, but how could you diagnose it?

Like any other patient you're suspicious of myocarditis? Echo, EKG, biomarker tests,etc...but if you have trouble getting phenylepherine...

 

[deleted875186]

I do not believe a HR of 170 was from volume depletion in a healthy OB patient.

something else going on. Some sort of SVT. Plus he said he treated her with 1L bolus and no response in the HR.

just my hunch, 170 seems way too fast for volume depletion. Would be interesting to see transition on ECG when she goes from 170 to 130 with positioning.

 

[GassYous]

I do not believe a HR of 170 was from volume depletion in a healthy OB patient.

something else going on. Some sort of SVT. Plus he said he treated her with 1L bolus and no response in the HR.

just my hunch, 170 seems way too fast for volume depletion. Would be interesting to see transition on ECG when she goes from 170 to 130 with positioning.

Agree. I've seen 150s but 170s is too high imo

 

[DrAmir0078]

Like any other patient you're suspicious of myocarditis? Echo, EKG, biomarker tests,etc...but if you have trouble getting phenylepherine...

Yes, same as phenylephrine issue!
But we got EKG on table as I said and was sinus Tachycardia. Echo is available, she is covid positive, no portable Echo, there is outpatient Echo clinic, and you know OBs they can manipulate the carse as Emergency, fetal in distress (many times they are uncooperative).
It is not my fault!
Their attitude, our limited resources and that sometimes 170 HR too (time consuming)

 

[deleted875186]

Yes, same as phenylephrine issue!
But we got EKG on table as I said and was sinus Tachycardia. Echo is available, she is covid positive, no portable Echo, there is outpatient Echo clinic, and you know OBs they can manipulate the care as Emergency, fetal in distress (many times they are uncooperative).
It is not my fault!
Their attitude, our limited resources and that sometimes 170 HR too (time consuming)

Ask a cardiologist at your hospital if they’ve ever seen sinus tachycardia to 170.

 

[DrAmir0078]

I do not believe a HR of 170 was from volume depletion in a healthy OB patient.

something else going on. Some sort of SVT. Plus he said he treated her with 1L bolus and no response in the HR.

just my hunch, 170 seems way too fast for volume depletion. Would be interesting to see transition on ECG when she goes from 170 to 130 with positioning.

Yes, her base HR was 135 after I pushed her uterus, that is reasonable isnat it, it was combined I belive, don't you think? The EKG was showing sinus beautiful tachycardia with very tempting P waves!

Something else, everything possible, like the second case I said, her dorsal hand skin was thick as a leather (very difficult to obtain an IV line), she Euothyroid, from the city not rural area her face... I hope I am not exaggerating the issue, but the first case was a bit over weight!

 

[DrAmir0078]

Ask a cardiologist at your hospital if they’ve ever seen sinus tachycardia to 170.

It is weird, and I said as even my Attending noticed that it reached 170, but mostly 150 - 160!
The pulse underneath my finger was very strong tachycardia, scary!
We've should asked our Cardiologist!
Next time!

 

[DrAmir0078]

Agree. I've seen 150s but 170s is too high imo

I believe in what I saw and with full honesty, I was presenting the case for you here.
It sometimes hit 170, but base 150s, 160s, even the probe is good shape and no problem in it and I can feel the radial pulse was very strong water hammer like.
But pushing the uterus, downed to 135 (beside she was dehydrated - it is combined), and myself I am not inventing facts that I didn't see.

 

[deleted875186]

Yes, her base HR was 135 after I pushed her uterus, that is reasonable isnat it, it was combined I belive, don't you think? The EKG was showing sinus beautiful tachycardia with very tempting P waves!

Something else, everything possible, like the second case I said, her dorsal hand skin was thick as a leather (very difficult to obtain an IV line), she Euothyroid, from the city not rural area her face... I hope I am not exaggerating the issue, but the first case was a bit over weight!

P waves does not mean sinus tachycardia, can have atrial contractions not arising from the sinus node that look similar to native p waves, especially hard to tell if it’s going fast. Sometimes can tell based on how the SVT breaks, when it went back down to 130.

 

[LifeofGas]

Fascinating! Thank you for the post!

Honestly, I only did LUD in residency and I have been lucky enough not to have dealt with refractory hypotension. When I started in the real world, I asked for it...and people just waved me off. In any case, I just remind myself that I will have to do that when patient get hypotensive. (I feel spoiled now because I have luxury of having Phenylephrine in my cart.)

But going back to your presentation, base on the limitation, no phenylephrine, I think GA is okay. I would imagine with spinal, if pressure tanks...it would be a pain to get it back up without Phenylephrine. With HR this high, I would tank her up more with fluid prior to starting. I would avoid metoprolol as the body is probably compensating for something (Hypovolemia...sepsis?) If her HR still that elevated... after good resuscitation, then I would look for possible cardiac etiologies.

 

[DrAmir0078]

P waves does not mean sinus tachycardia, can have atrial contractions not arising from the sinus node that look similar to native p waves, especially hard to tell if it’s going fast. Sometimes can tell based on how the SVT breaks, when it went back down to 130.

I understand, thanks for the info. I came to the OBs floor requesting her OR ECG and couldn't find it, but I found in her record post op EKG and Echo - my request, and interestingly her T4 is elevated too ! - a hyperthyroidism? Does this explain more vividly her Tachycardia beside Aortocaval + Dehydration.
I am so mad, I couldn't find the OR EKG, the OBs thought something wrong, but I told them about my ongoing discussion and how important Aortocaval and showed them my Google form, I am going and trying to convince them to participate with these questionnaires' like survey!

Again, I confirmed with the PGY1 her EKG was sinus Tachycardia over 130, can't remember the rate, the strip is gone, my apologies!

 

[DrAmir0078]

Fascinating! Thank you for the post!

Honestly, I only did LUD in residency and I have been lucky enough not to have dealt with refractory hypotension. When I started in the real world, I asked for it...and people just waved me off. In any case, I just remind myself that I will have to do that when patient get hypotensive. (I feel spoiled now because I have luxury of having Phenylephrine in my cart.)

But going back to your presentation, base on the limitation, no phenylephrine, I think GA is okay. I would imagine with spinal, if pressure tanks...it would be a pain to get it back up without Phenylephrine. With HR this high, I would tank her up more with fluid prior to starting. I would avoid metoprolol as the body is probably compensating for something (Hypovolemia...sepsis?) If her HR still that elevated... after good resuscitation, then I would look for possible cardiac etiologies.

Thanks a lot for bringing up your experience. It is what it is here in Iraq with limitations!
I did my best and load her with fluid, beside those small doses of metoprolol and I didn't give more than 0.8 mg on 0.2 mg every 5 to 10 minutes and check the response with fluid going in.

That is why we feard spinal!

I uploaded some of her records up... Post Op EKG, Post Op Echo and unfortunately no OR EKG found... Beside she got elevated T4, and could've add extra layer of Tachycardia!?

 

[MirrorTodd]

I uploaded some of her records up... Post Op EKG, Post Op Echo and unfortunately no OR EKG found... Beside she got elevated T4, and could've add extra layer of Tachycardia!?

I'm pretty sure thyroid hormone levels are expected to rise in pregnancy dude to the similarity between hcg and tsh. I think you would've needed to do more extensive lab analysis (free t3, t4, tsh, thyroid binding etc) if you had really wanted to determine if she was hyperthyroid. Seems like she got better after the baby was out though, so all's well that ends well I guess.

 

[PlayToWin]

You can easily substitute a an unopened bag of 1 L LR and place it under pads of bed . Seems like fluids was necessary and have a Nirse or resident also do manual compression if needed.

 

[DrAmir0078]

I'm pretty sure thyroid hormone levels are expected to rise in pregnancy dude to the similarity between hcg and tsh. I think you would've needed to do more extensive lab analysis (free t3, t4, tsh, thyroid binding etc) if you had really wanted to determine if she was hyperthyroid. Seems like she got better after the baby was out though, so all's well that ends well I guess.

Indeed, it is not reliable, we were aware, me and my Attending.
But I was questioning every single detail!
Many thanks