Clinical Case #441

[coccygodynia]

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Here's my contribution to the clinical scenarios being shared. A case from this past weekend ...

28yo G7P5, 27weeks gestation in for unwanted pregnancy and laparoscopic BTL. Hx of pregnancy induced nonischemic CMO, severe AI(3/6 murmur), mild MR, dilated aortic root, dilated LV/LA, EF 20-25%. Was dx with the CMO on her fifth pregnancy, told further pregnancies would be detrimental to her and the baby's health. Meds: coreg, digoxin, lasix (all taken this am). Sent to our facility from a much smaller one for above reasons.

Vitals: 118/23, 74, 95% on RA, RR 16-18
18g IV

What should we do?

 

[Noyac]

Sh*te, I really don't miss those cases. B/4 I get involved, whats CMO? I am horrible with abrev's.

BP 118/23 Nice!!! That AI is real.

 

[coccygodynia]

LOL ... I forgot you hate abbreviations. CMO = cardiomyopathy

 

[Noyac]

LOL ... I forgot you hate abbreviations. CMO = cardiomyopathy

I hate them only cause I am too stupid to figure them out and then I get reminded that I am stupid. About approaching this case, I like to give some of our residents and srna's a chance to comment first.

 

[Idiopathic]

Here's my contribution to the clinical scenarios being shared. A case from this past weekend ...

28yo G7P5, 27weeks gestation in for unwanted pregnancy and laparoscopic BTL. Hx of pregnancy induced nonischemic CMO, severe AI(3/6 murmur), mild MR, dilated aortic root, dilated LV/LA, EF 20-25%. Was dx with the CMO on her fifth pregnancy, told further pregnancies would be detrimental to her and the baby's health. Meds: coreg, digoxin, lasix (all taken this am). Sent to our facility from a much smaller one for above reasons.

Vitals: 118/23, 74, 95% on RA, RR 16-18
18g IV

What should we do?

is this case for delivery or termination?

edit: i assume she/fetus is in distress, so im guessing that she will be delivered via caesarean. i say spinal and ketamine, no agent, and finish the case by giving her a new set of valves and removing her uterus.

but im just talking out my ass

 

[militarymd]

Minor surgery....prop/sux/tub....neo for hypotension....plus or minus on a-line....probably minus.


sodium restrict for the case

 

[militarymd]

Minor surgery....prop/sux/tub....neo for hypotension....plus or minus on a-line....probably minus.


sodium restrict for the case

I guess minor if you have a good OB...but technically intermediate risk...and I guess SAB here in N. America, but I prefer GETA.

 

[Noyac]

I'm confused (not unusual) but is this a termination of pregnancy b/c of CMO or elective? You stated unwanted. Why the HELL did she wait 20weeks?

PS: Mil , you are not a resident. You must wait to respond.

 

[militarymd]

I'm confused (not unusual) but is this a termination of pregnancy b/c of CMO or elective? You stated unwanted. Why the HELL did she wait 20weeks?

PS: Mil , you are not a resident. You must wait to respond.

solly

 

[coccygodynia]

I'm confused (not unusual) but is this a termination of pregnancy b/c of CMO or elective? You stated unwanted. Why the HELL did she wait 20weeks?

PS: Mil , you are not a resident. You must wait to respond.

She showed up in a small-town ER complaining of SOB. They did a slew of tests, and found out she was pregnant (she states she "did not know" ... 😕 ). So yes, she was in for a D&C with BTL d/t risk of death to mom and baby.

BTW - she's 5'6 and 49kg. I'll say what we did after a few.

 

[Noyac]

I'm on the same page a Mil here. I would do GETA but I would try ephedrine for hypotension first cause I want to keep the HR up with severe AI. Be aware though that she may not tolerate abd insufflation very well (as the abd pressure may increasethe aortic regurg) and you may need to tell them to abandon the laproscopic BTL for the standard mini open type. Although not necessary, I would probably put an Aline for cont BP. No CVP No Swan No TEE. This case should be done in well under an hour.

 

[coccygodynia]

Since the procedure wasn't going to take long, we did the following:

Dobutamine in line, Amidate 10mg, Roc 30, mask ventilate with Sevo to a MAC of 2, once hemodynamics optimal DL <10sec, intubate and that's it. She needed the dobutamine with induction (HR down to 60) and during certain parts of the procedure. Couldn't give the surgical team as much Tburg as they wanted, but they managed. Awake and to MICU for the night.

 

[militarymd]

Since the procedure wasn't going to take long, we did the following:

Dobutamine in line, Amidate 10mg, Roc 30, mask ventilate with Sevo to a MAC of 2, once hemodynamics optimal DL <10sec, intubate and that's it. She needed the dobutamine with induction (HR down to 60) and during certain parts of the procedure. Couldn't give the surgical team as much Tburg as they wanted, but they managed. Awake and to MICU for the night.

How do you define "She needed the dobutamine with induction..."?

 

[coccygodynia]

How do you define "She needed the dobutamine with induction..."?

We went with dobutamine d/t the drop in BP/HR ... seemed the best choice with her low EF. It worked without causing a dramatic rise in the BP.

 

[militarymd]

Usually you don't treat bradycardia with an inotrope. She's been walking around with a low EF all this time, why would she need an inotrope after induction when cardiac output needs are lower???

As anesthesiologists, we always think of the "failing LV"....per after a pump run...where the LV has been cold, ischemic, stunned, etc....a situation where the myocardial failure IS a concern.

But the garden variety low EF'ers who get put to sleep DO NOT need inotropes. The patients may become hypotensive, but SO DO many patients who have normal EFs....we don't treat them with inotropes....

I guess my point is...just because someone has a low EF, does not mean you use an inotrope for hypotension....

Myocardial failure under GA...regardless of EF....is EXTREMELY rare.

 

[Laryngospasm]

Since the procedure wasn't going to take long, we did the following:

Dobutamine in line, Amidate 10mg, Roc 30, mask ventilate with Sevo to a MAC of 2, once hemodynamics optimal DL <10sec, intubate and that's it. She needed the dobutamine with induction (HR down to 60) and during certain parts of the procedure. Couldn't give the surgical team as much Tburg as they wanted, but they managed. Awake and to MICU for the night.

Why not just titrate in ephedrine with the induction as needed?

 

[coccygodynia]

Why not just titrate in ephedrine with the induction as needed?

We discussed using this, but assumed she had depleted endogenous catecholamine stores, so the ephedrine would only buy us a little time.

Mil - I see your point. We were being extremely cautious with her (a bit too cautious?) drop in BP. Couldn't give her a great amount of fluid preinduction to help out with the hypotension, so my attending thought an inotrope would serve us best. Thanks for your input.

 

[militarymd]

Go into the heart room and watch one of those cases. After induction, but before CPB, see what drugs are used to treat hypotension in patients with low EF......I suspect you will see phenylephrine used.

 

[SilverStreak]

Go into the heart room and watch one of those cases. After induction, but before CPB, see what drugs are used to treat hypotension in patients with low EF......I suspect you will see phenylephrine used.

Yep, if fluids are not doing it for the hypotension or they don't want to use a lot of fluids, neo is the first drug they'll start.

 

[toughlife]

Yep, if fluids are not doing it for the hypotension or they don't want to use a lot of fluids, neo is the first drug they'll start.

could you explain how neo helps in hypotension?

 

[Idiopathic]

.

 

[Idiopathic]

Why even mess with GETA in this case? Do you just specifically not want to block her or was it just preference in her case. Is that diastolic pressure the main reason, or is it that you feel any drop in CO associated with the spinal will end it all? On the right track here?

 

[versaitle_kat]

.

 

[coccygodynia]

Why even mess with GETA in this case? Do you just specifically not want to block her or was it just preference in her case. Is that diastolic pressure the main reason, or is it that you feel any drop in CO associated with the spinal will end it all? On the right track here?

I think toughlife specifially wanted silverstreak to answer his question because s/he is nurse and he assumes s/he has no clue as to the pharmacology of neo (which is a poor assumption to make, since most seasoned ICU nurses know how alpha-adrenergic agents work).

We didn't want to tempt fate by giving her SAB, since she would be exquisitely sensitive to any alterations in preload and afterload.

 

[militarymd]

We didn't want to tempt fate by giving her SAB, since she would be exquisitely sensitive to any alterations in preload and afterload.

That's a load of you know what.

 

[Idiopathic]

I think toughlife specifially wanted silverstreak to answer his question because s/he is nurse and he assumes s/he has no clue as to the pharmacology of neo (which is a poor assumption to make, since most seasoned ICU nurses know how alpha-adrenergic agents work).

I see, after I typed it up I realized it might have been a loaded question.

 

[toughlife]

I think toughlife specifially wanted silverstreak to answer his question because s/he is nurse and he assumes s/he has no clue as to the pharmacology of neo (which is a poor assumption to make, since most seasoned ICU nurses know how alpha-adrenergic agents work).

We didn't want to tempt fate by giving her SAB, since she would be exquisitely sensitive to any alterations in preload and afterload.

I only know the generic names for drugs and, until now that I just looked it up, was not aware that another name for phenylephrine is neo-synephrine.

 

[coccygodynia]

That's a load of you know what.

LOL ... school me, oh great one 🙂 .

What I've read about patients with noncompliant ventricles (and what's been taught to me) says exacty what I wrote. I'm sure that once I've gotten the experience that you and the rest of the guru's have, I'll be singing another tune. You know what p u s s i e s us newbies are with fragile patients!