clinical case: consultation for elective c-section

[urge]

---

Members do not see this ad.

pent sux tube

 

[Robert Loblaw]

how it played out:

so we had a long discussion with the patient and detailed all the things discussed above--the risk of epidural hematoma, the risk of MH, the possibility that she did not have a sux allergy but INSTEAD had a difficult airway that was not clearly documented. one thought we had that hasn't been mentioned is to transfuse platelets as planned for the c-section and monitor function with a TEG. theoretically, once the concentration of transfused platelets is enough, cross linking will occur which can be measured by the TEG. unfortunately for various political and quality control reasons, our hospital laboratory has blocked attempts at obtaining TEG in the ORs so this was unavailable to us.

i did not do the case but followed up with the colleague who did. ultimately, the patient came for elective c-section, got her platelets and had a non-triggering anesthetic with roc/glidescope (not available during the first c-section) without any hitches. mom and baby did well.

 

[Robert Loblaw]

The presence of antiplatelet antibodies meant that platelet transfusions might not be effective. Native blood Thrombelastograph® analysis was performed at this stage, which showed normal clot initiation but poor clot strength (Fig. 1). With this information in mind, we decided that regional anaesthesia was contraindicated and that peripartum haemorrhage was inevitable. An illustration of the Thrombelastograph® indices measured is given in Figure 2.


http://bja.oxfordjournals.org/content/88/5/734.full#ref-1

Too funny, we reviewed this report after the consultation. There really isn't much in the literature.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/15493726


Platelet counts, platelet morphology, prothrombin, and activated thromboplastin times are all within normal ranges in patients with Glanzmann's thrombasthenia.


Did you read this one?

 

[Robert Loblaw]

http://www.ncbi.nlm.nih.gov/pubmed/15493726


Platelet counts, platelet morphology, prothrombin, and activated thromboplastin times are all within normal ranges in patients with Glanzmann's thrombasthenia.


Did you read this one?

Don't recall. Looked it up in Chestnut and Stoelting's...We were all stricken with how 'oral boardsy' this consultation was turning out.

 

[BLADEMDA]

how it played out:

so we had a long discussion with the patient and detailed all the things discussed above--the risk of epidural hematoma, the risk of MH, the possibility that she did not have a sux allergy but INSTEAD had a difficult airway that was not clearly documented. one thought we had that hasn't been mentioned is to transfuse platelets as planned for the c-section and monitor function with a TEG. theoretically, once the concentration of transfused platelets is enough, cross linking will occur which can be measured by the TEG. unfortunately for various political and quality control reasons, our hospital laboratory has blocked attempts at obtaining TEG in the ORs so this was unavailable to us.

i did not do the case but followed up with the colleague who did. ultimately, the patient came for elective c-section, got her platelets and had a non-triggering anesthetic with roc/glidescope (not available during the first c-section) without any hitches. mom and baby did well.

I agree with you but would have added Factor VII and maybe Tranxemic acid.


"A gamma globulin infusion was given to our patient on the night before surgery in an attempt to dampen this antiplatelet response. The rationale for prescribing rFVII was based on the theory that factor VII acts on platelets in the absence of tissue factor, to activate factors IX and X, thus enhancing thrombin generation. The increased generation of thrombin may then provide a strong signal for the recruitment of other platelets.5 Treatment with rFVII is well tolerated generally, although hugely expensive."

 

[BLADEMDA]

At 31 weeks' gestation the patient developed unremitting epistaxis. Her nose was packed, she was prescribed tranexamic acid, and the bleeding subsided.


http://bja.oxfordjournals.org/content/88/5/734.full#ref-1

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/19657319

http://www.ncbi.nlm.nih.gov/pubmed/16444446


I would have added low dose Factor VII at the start of the case and be prepared to give full dose Factor VII.

 

[doctor712]

no, not directed at you, just in general. you gave a very insightful answer, even more so considering your experience (i'm not being sarcastic, this is a compliment).

Appreciate it RL, mucho obligato.

D712

 

[pd4emergence]

I agree with the tranexamic acid or amicar, I think I would avoid the factor vii use until there was uncontrolled bleeding. I assume this lady did fine without either in her previous c section. I think the reason why they threw everything at that case report was that she had anti platelet antibodies and they didn't think the platelets were going to be effective.

 

[pd4emergence]

how it played out:

so we had a long discussion with the patient and detailed all the things discussed above--the risk of epidural hematoma, the risk of MH, the possibility that she did not have a sux allergy but INSTEAD had a difficult airway that was not clearly documented. one thought we had that hasn't been mentioned is to transfuse platelets as planned for the c-section and monitor function with a TEG. theoretically, once the concentration of transfused platelets is enough, cross linking will occur which can be measured by the TEG. unfortunately for various political and quality control reasons, our hospital laboratory has blocked attempts at obtaining TEG in the ORs so this was unavailable to us.

i did not do the case but followed up with the colleague who did. ultimately, the patient came for elective c-section, got her platelets and had a non-triggering anesthetic with roc/glidescope (not available during the first c-section) without any hitches. mom and baby did well.

Great case, I will be honest, I can't remember ever hearing about glanzmann's before this thread. Thanks for posting.

 

[Robert Loblaw]

i can't recall thinking of using amicar (TA not on formulary) and i'm not sure whether it was done for the actual case. it is a good thought, however, in retrospect, although i think the evidence regarding its efficacy is not conclusive.

 

[Robert Loblaw]

Great case, I will be honest, I can't remember ever hearing about glanzmann's before this thread. Thanks for posting.

yeah, i remember after explaining the multiple conundrums to the patient, who was, as i said, a university researcher, she sort of "got it" and said something tinged with disbelief as to how difficult it would be to decide between all the multiple unpleasant scenarios.

 

[Noyac]

do we not like mh distance anymore? i was merely trying to convey in common parlance that her face head and neck was not worrisome for difficult intubation. my own personal feelings are that each practitioner develops a gestalt-type airway exam that is based on experience and subtle cues. for example, i tend to notice when the mandibular incisors are bunched together and overlapping, suggesting a narrow jaw.

she was extubated at the end of the case, if i recall correctly.

We are not picking on you at all. We understand what you mean by my distant. We were just having some fun with the terms mh and MH. But to be clear , I call it TM distance.

 

[Robert Loblaw]

We are not picking on you at all. We understand what you mean by my distant. We were just having some fun with the terms mh and MH. But to be clear , I call it TM distance.

i will be in the minority of posters on the forum who will refuse to be 'offended' by anything written on this forum, so no worries. that's what i thought, i just wasn't sure if i was missing something 👍