clinical thread (OB)

[IN2B8R]

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Here we go: real life patient in a PP setting, large sized hospital, you are on call with 2 CRNA's.

OB direct page to anesthesiologist: Hi Dr. X, I have a c-section that "needs to go within one hour."
Anesthesiologist: wuda ya got, Liz?
OB: I don't want her to labor, she has a Hx of congential heart dz.
Anesthesiologist: specifically?
OB: "some pulmonic stenosis," but "she saw someone...."
Anesthesiologist: did she have an echo?
OB: not really sure, but I'll check....Think you'll be ready in about one hour, we really don't want her laboring...?

Background info on pt: typical fat arse, 135kg, 19 y.o. smoker with "fiancee" flat on his back in corner of room. Term pregnancy. Folate/MVI. CHD remarkable for pulmonic stenosis, s/p balloon dilatation when pt was "young--4 yrs old?!" 2005 Echo shows PV peak gradient of 55 mmhg. On exam: some SOB during pregnancy (nothin outa ordinary...), wreaks of nicotine, fat, no observable signs of right heart failure.

Lets have it: your concerns and plan. Will tell you what we did.

 

[periopdoc]

Is there also an ASD? (frequently associated).

What is the velocity across the tricuspid valve and what is the RV size and thickness?

The pulmonary vasculature is protected by the valvular stenosis so PVR won't be high and you don't have to worry about hypoxia and hypercarbia any more than you would in a normal patient.

Tricuspid regurg is likely severe. This protects the RV from hypertrophy and dilation despite high systolic RV pressures. However, it predisposes to hepatic issues. How is her synthetic function/ coags?

Assuming this is isolated pulmonic stenosis as evidenced by estimated PA pressure from the TR jet, +/- A-line, routine ASA monitors, load with 1 liter of crystalloid, phenylephrine drip in line. Normal spinal, but have her lay down slowly. (private practice plan)

If you were at my institution where c-sections take a couple of hours, I would do a CSE.


- pod

posted from my iPhone

 

[periopdoc]

I should add that a gradient of 55 mm Hg is resoundingly moderate. < 36 mm Hg is mild, 36-64 mm Hg is moderate, and > 64 mm Hg is severe.

I would also look at the shape of the pulmonic velocity flow curve (toss on a trans-thoracic myself if I didn't have access to the images from the earlier study). Isolated valvular stenosis should be early-peaking. If there is a late-peaking dagger shape to the velocity flow curve, then there is a likely a dynamic RVOT component to the stenosis and I would be more worried about decompensation with hemodynamic shifts.

- pod

 

[Boujee]

Hey periop,
why do u suspect severe TR? thanks...

 

[IN2B8R]

DeamMachine--she had PV stenosis, s/p balloon valvuloplasty done when she was younger. Pulm HTN was a non issue. She has been clinically asymptomatic since her procedure, in spite of the gradient reported from a previous echo that showed a peak gradient in the 50s. What concerned me was that the echo report stated that it had "poor windows." It was not a TTE (which is what's best for PV interoggation), but it was a TEE. Nonethless, gradients are gradients, they are dependent on many factors and I felt comfortable proceeding with a spinal without an a-line. I used isobaric 0.75% bupiv (1.6ml) with a little fentanyl and the case went fine. I thought that this was an interesting case, since PV stenosis is rare, in addition to the fact that when I was a resident, I did recall a pregnant girl with more severe symptoms who had a spinal and had a very bad outcome....




QUOTE=DreamMachine;9135003]My hemodynamic goals are to avoid hypotension, avoid tachycardia, avoid increases in pulmonary vascular resistance, maintain NSR, maintain contractility (ionotropy), and maintain intravascular volume status.

I would insert an arterial line and a TLC.

I would preload her up to 2 liters. I would slowly dose an epidural while keeping her on a 100 percent face mask and likely using phenylephrine as my vasopressor of choice.

Did I f*ck it up?[/QUOTE]

 

[IN2B8R]

Periopdoc--don't hold me to it, but if I remember correctly, I think that pts with a gradient less than 50mm hg who are asymptomatic tend to have normal life expectancies. This pt's RV was not hypertrophied and she only had mild TR. I did a TTE by the bedside: very little PV regurg was noticed, with an otherwise relatively normal RV size & fxn. Gradient across valve was 40 mmhg, with an early peaking flow curve. No ASD noted. What I did was an isobaric spinal (0.75% bupiv) with 30mcg fent. Worked like a charm and sympathetomy was more than tolerated (used neo only once--100mcg bolus). She did get a liter LR fluid bolus prior to spinal placement. CRNA could not get spinal on three initial passes, I took over and drove it home with a 24ga non-cutting spinal needle. It was a good, rare, case. Had her stenosis been worse, I likely would have titrated in an epidural with the presence of an A-line. She was fat with not much of a chin, so I really didn't want to intubate her fat arse

I should add that a gradient of 55 mm Hg is resoundingly moderate. < 36 mm Hg is mild, 36-64 mm Hg is moderate, and > 64 mm Hg is severe.

I would also look at the shape of the pulmonic velocity flow curve (toss on a trans-thoracic myself if I didn't have access to the images from the earlier study). Isolated valvular stenosis should be early-peaking. If there is a late-peaking dagger shape to the velocity flow curve, then there is a likely a dynamic RVOT component to the stenosis and I would be more worried about decompensation with hemodynamic shifts.

- pod

 

[militarymd]

Periopdoc--don't hold me to it, but if I remember correctly, I think that pts with a gradient less than 50mm hg who are asymptomatic tend to have normal life expectancies. This pt's RV was not hypertrophied and she only had mild TR. I did a TTE by the bedside: very little PV regurg was noticed, with an otherwise relatively normal RV size & fxn. Gradient across valve was 40 mmhg, with an early peaking flow curve. No ASD noted. What I did was an isobaric spinal (0.75% bupiv) with 30mcg fent. Worked like a charm and sympathetomy was more than tolerated (used neo only once--100mcg bolus). She did get a liter LR fluid bolus prior to spinal placement. CRNA could not get spinal on three initial passes, I took over and drove it home with a 24ga non-cutting spinal needle. It was a good, rare, case. Had her stenosis been worse, I likely would have titrated in an epidural with the presence of an A-line. She was fat with not much of a chin, so I really didn't want to intubate her fat arse

I am impressed...not many of us know how to do one of those.....during my fellowship, I personally performed 200+ TTE....and I have found that it was one of the best things that I ever did in training.


and I agree.....plain spinal anesthetic

 

[IN2B8R]

It's a skill that every PP guy should have, bro'. There are countless pts that I do this pre-op on, namely because either the pt cannot give me a good assessment of their exercise tolerance, or their surgeon never gave a **** about having them properly worked up (and this happens very often with our vascular guys). My word over that of the cardiologists around me. And that's no BS. I take that from my personal experiences, been burned one too many times by those who have no clue about what I specifically do.

I am impressed...not many of us know how to do one of those.....during my fellowship, I personally performed 200+ TTE....and I have found that it was one of the best things that I ever did in training.


and I agree.....plain spinal anesthetic

 

[periopdoc]

I am impressed...not many of us know how to do one of those.....during my fellowship, I personally performed 200+ TTE....and I have found that it was one of the best things that I ever did in training.

That's why I spent a month of my fellowship doing TTE with the cardiologists in their lab and 2 months of ICU doing as many TTEs as possible. IMHO it is a more useful skill than TEE. Minimal risk, big benefit, useful in all types of patients, no contraindications, non-invasive, and I don't have to wait for cards to clear my patients. Should be a component of all resident training.

-pod

 

[MDEntropy]

I don't want to come across as hijacking this thread. It's a nice case. I am not sure if we are gonna discuss it much more, so I will ask about another case. Not complicated but answers may vary and I am curious.

27y/o Para 3 twin gestation morbidly obese MP4. Decision to C/S due to recent non-reactive NST. Earlier patient stated that she ate at 4am, so plan is for section at noon. Just before going into OR patient states that during her NST 2hours ago, she had "regular" orange juice. Can't remember if there was pulp etc. Would you proceed or wait? And if you will wait, how long? Zero pressure from obstetric team. The ASA guidelines certainly provide some minimum waiting periods but there seems to be a fair amount of wiggle room. Pt also states she had "itching, nausea, and trouble breathing" with IV morphine a few years ago after a minor procedure. Do you put pf morphine in your spinal?

 

[militarymd]

I don't want to come across as hijacking this thread. It's a nice case. I am not sure if we are gonna discuss it much more, so I will ask about another case. Not complicated but answers may vary and I am curious.

27y/o Para 3 twin gestation morbidly obese MP4. Decision to C/S due to recent non-reactive NST. Earlier patient stated that she ate at 4am, so plan is for section at noon. Just before going into OR patient states that during her NST 2hours ago, she had "regular" orange juice. Can't remember if there was pulp etc. Would you proceed or wait? And if you will wait, how long? Zero pressure from obstetric team. The ASA guidelines certainly provide some minimum waiting periods but there seems to be a fair amount of wiggle room. Pt also states she had "itching, nausea, and trouble breathing" with IV morphine a few years ago after a minor procedure. Do you put pf morphine in your spinal?

I wouldn't wait...what's the point?

and she goes to sleep.

 

[sevoflurane]

I'd remove morphine from the picture. I can't stand watching patients break out in hives and c/o itching, which is why I only use 150 mcgs of duramorph with my spinals. It makes me wanna itch. I don't see it with this dose. I'd do a spinal and maintain my AW reflexes. She will probably get some n/v, but a lot of them do anyways.

 

[sevoflurane]

I'm assuming you have decent OB who can do their job in a reasonable amount of time. Less than 1 hr. C/S. Add 15 minutes if they are morbidly obese.

 

[monchi]

How strictly do people follow the NPO rules for c-sections?

My understanding of it is that 1) pregnant pts are considered "full stomach" all the time, and 2) an awake pt can protect their AW reflexes.
So, it's better to do the spinal, even if they recently ate.

I do agree though, that even though they are "full" all the time, it's probably better if they haven't just eaten a Big Mac.

Where I'm training, it's happened a few times for me that a pt comes in to L&D right after stopping a McD's. They get admitted then OBs want an urgent section a couple hrs later. I've done' spinals if there was enough time.

In PP, is this the common practice?

 

[militarymd]

around 5 pm, they always declare that it is an emergency....

 

[IN2B8R]

She's full stomach and will always be. I don't like surgeons waiting on anything. Plain spinal. PCA post-op. Next case.

I don't want to come across as hijacking this thread. It's a nice case. I am not sure if we are gonna discuss it much more, so I will ask about another case. Not complicated but answers may vary and I am curious.

27y/o Para 3 twin gestation morbidly obese MP4. Decision to C/S due to recent non-reactive NST. Earlier patient stated that she ate at 4am, so plan is for section at noon. Just before going into OR patient states that during her NST 2hours ago, she had "regular" orange juice. Can't remember if there was pulp etc. Would you proceed or wait? And if you will wait, how long? Zero pressure from obstetric team. The ASA guidelines certainly provide some minimum waiting periods but there seems to be a fair amount of wiggle room. Pt also states she had "itching, nausea, and trouble breathing" with IV morphine a few years ago after a minor procedure. Do you put pf morphine in your spinal?

 

[IN2B8R]

That's why I spent a month of my fellowship doing TTE with the cardiologists in their lab and 2 months of ICU doing as many TTEs as possible. IMHO it is a more useful skill than TEE. Minimal risk, big benefit, useful in all types of patients, no contraindications, non-invasive, and I don't have to wait for cards to clear my patients. Should be a component of all resident training.

-pod

Nice post. Right on the money.👍

 

[MDEntropy]

She's full stomach and will always be. I don't like surgeons waiting on anything. Plain spinal. PCA post-op. Next case.

She got a spinal with a 'regular' dose of pf morphine.

Do you not consider fasting important in this population? In other words, everyone's a full stomach so no point in considering their npo status? She was not in labor, but certainly term. Surgeons not applying any pressure, just looking to you to tell what the right thing to do is.

 

[militarymd]

She got a spinal with a 'regular' dose of pf morphine.

Do you not consider fasting important in this population? In other words, everyone's a full stomach so no point in considering their npo status? She was not in labor, but certainly term. Surgeons not applying any pressure, just looking to you to tell what the right thing to do is.

overall OVERRATED.

if you enjoy sitting around in the hospital engaged in NON-BILLABLE activities....then by all means....wait....and why not make it 8 hours....that's really not that unreasonable either.

10 year ago....I thought those magic npo hours are really important....now I know it's a farce....

 

[GoodmanBrown]

Quick question regarding TTE:

The only experience I have with it was in an outpatient cardiology setting. The cards doc ordered the echo, a technician came in eventually and did it, then the cards doctor read it awhile later.

For you all, does anyone else read the echo? I'm assuming that you do it yourself while doing the pre-op. Do you bill for both the procedure and review?

 

[sevoflurane]

Quick question regarding TTE:

The only experience I have with it was in an outpatient cardiology setting. The cards doc ordered the echo, a technician came in eventually and did it, then the cards doctor read it awhile later.

For you all, does anyone else read the echo? I'm assuming that you do it yourself while doing the pre-op. Do you bill for both the procedure and review?

I don't bill for TTE and honestly, I don't use it much although I should. I do for TEE.

You should start using TTE now. I started during early residency. Especially on call. I'd be in the middle of a trauma or interesting case or even routine case and ask for the portable echo machine. The technician would bring it in and I'd start playing with it under the drapes. You need someone qualified to really teach you TTE, but you can gain a tremendous amount of knowledge using it on routine cases or on your fellow residents. You need to look at a bunch of echos before you know what is nml and what is not anyways. It is a risk-free procedure and a good opportunity to learn.

 

[sevoflurane]

Oh... wait... you aren't in medical school yet?? Big questions for someone in undergrad. 👍

 

[militarymd]

I don't bill for it...I use it like I would use any other monitor.

 

[IN2B8R]

I generally do what is easiest for me: do not like to leave cases on the back burner if I can help it, since I work in a busy place and call cases tend to stack up if not addressed right away (I like to get the backup call guy out ASAP, that way I get same favor when I'm backup call...). Anyhow, regarding your questions: at our hospital, OB runs PCA's for all post-op sections, thus negating the need for IT MSO4. That pleases me, since, as alluded to above, it makes my life easier.... As for fasting: I consider npo status to be full, even if npo since 8 hours ago. If it really bothers you to place a spinal on a full stomach, then give Bicitra, that usually causes nice barfing pre-op and has a similar effect to passing an OGT . And no, I don't use Bicitra at all. At the end of the day, if the surgeon wants to go now, I try to get the case out of the way. If they wanna wait, then I'll wait. NPO status in gravid OB patient is perhaps the grayest of all areas.... definitely practice area dependent.

She got a spinal with a 'regular' dose of pf morphine.

Do you not consider fasting important in this population? In other words, everyone's a full stomach so no point in considering their npo status? She was not in labor, but certainly term. Surgeons not applying any pressure, just looking to you to tell what the right thing to do is.

 

[GoodmanBrown]

Oh... wait... you aren't in medical school yet?? Big questions for someone in undergrad. 👍

Thanks for the shout-out! You're right that I'm not in med school yet, but I'm starting this fall. I'm actually non-trad, so I've been out of undergrad for about 6 years. Got into my present career without much foreknowledge of what it actually entailed.

The anesthesiology forum and SDN in general have been really helpful in giving me a better idea of what I'm in for. This forum actually got me interested in anesthesiology and I've been able to shadow anesthesiologists for about 25 hours already. The best clinical threads on SDN are in this forum, hands down.