Csection case

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GassYous

GassYous

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30 yo f with severe AS and BMI 52. Covid positive. Can't lay flat at good times and now is satting low 90s on nrb. What's your plan?

Not my case but a real one.
 
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I think finagling with her pulm status mid-case would be a huge pain.

Gently bolusing epidural or even an intrathecal catheter is an option as well but too much stress for not much gain. Respecting the OB airway is important but low 90s on NRB gives you very little room if this is a patient who can’t tolerate that peritoneal tugging, for instance.

I’d start her on peripheral neo and just go to sleep. Would place pre-induction art line. Skip straight to glidescope. Make her drink that horrible Bicitra beforehand.
 
gcc322 said:
I love bicitra. That’s my go to when I get heartburn and stuck at the hospital.
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I have attendings who don’t like it when I order it. Concerned that the apparently nasty taste might push the pregnant patient over the edge.
 
FiO2@21 said:
I think finagling with her pulm status mid-case would be a huge pain.

Gently bolusing epidural or even an intrathecal catheter is an option as well but too much stress for not much gain. Respecting the OB airway is important but low 90s on NRB gives you very little room if this is a patient who can’t tolerate that peritoneal tugging, for instance.

I’d start her on peripheral neo and just go to sleep. Would place pre-induction art line. Skip straight to glidescope. Make her drink that horrible Bicitra beforehand.
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How would you induce? How would you tube?

Where would you do the case?

Any other lines?

What if she just sucked down a milkshake from chick fil a?
 
coffeebythelake said:
How did she get pregnant in the first place? Curious
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No clue but the guy must be related to Ron Jeremy.

Biden keeps going on about Americans going hungry but the next medicaid patient I see that is below 30 bmi will be the first. Except the homeless druggies I suppose.
 
GassYous said:
No clue but the guy must be related to Ron Jeremy.

Biden keeps going on about Americans going hungry but the next medicaid patient I see that is below 30 bmi will be the first. Except the homeless druggies I suppose.
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Yeah... Fries and hamburgers and crap food is lot cheaper than wholesome good food. I don't think it is necessarily the right thing to say that poor people should be thin. I can't figure out if u are saying what I'm saying..
 
GassYous said:
30 yo f with severe AS and BMI 52. Covid positive. Can't lay flat at good times and now is satting low 90s on nrb. What's your plan?

Not my case but a real one.
Click to expand...

Art line. Tube. Plenty of phenylephrine ready. Watch preload. Youve already said she can't lay flat.. Even if u manage to place and dose up an epidural without crashing her pressures, how are u going to lay her down to do thr c section?

Ideally should have had high risk OB monitor her through pregnancy and optimize her clinical status, (and also tell her well ahead of time how risky her pregnancy is)
 
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GassYous said:
How would you induce? How would you tube?

Where would you do the case?

Any other lines?

What if she just sucked down a milkshake from chick fil a?
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Etomidate, RSI dose roc no matter what the NPO status is. Ketamine added if I get that gut feeling that a vial of etomidate might not be enough to get her down. Phenylephrine gtt starting before I induce.

I would prefer main OR. But predict this was done in L&D...

Depends on current IV access. Crystal ball tells me she’ll have a 22 G. If I can’t get a quick u/s IV I’ll want a central line. But under the drapes. No need to delay incision after induction on account of my line. I predict she might not tolerate laying still for an awake line, but if she can I will.
 
GassYous said:
30 yo f with severe AS and BMI 52. Covid positive. Can't lay flat at good times and now is satting low 90s on nrb. What's your plan?

Not my case but a real one.
Click to expand...
How bad is the AS?
 
GassYous said:
How would you induce? How would you tube?

Where would you do the case?

Any other lines?

What if she just sucked down a milkshake from chick fil a?
Click to expand...
Rightfully so, I do think more information would be helpful but the end result would be the same. So how would I get there?

Induction? Tube?
I'm sure the OB has some info on the severity of the AS. For academic purposes of the forum, I'd probably place an art line pre-induction (ICU will get us of it for ABGs anyway). (For non-academic purposes, I'd have an U/S in the room and I'm experienced so I would even consider just inducing and placing the line afterward). A glidescope is a definite here. I think sometimes we get a bit uptake about "BMI" when the reality is you need to do an airway exam to make your decision. I've had 60 BMI patients that were easier intubations thank 50 kg old ladies.

Case?
Everything in the case presentation pushes me towards a GETA. If she were just obese with COVID, a spinal would be fine so long as everyone has PPE. This patient has a low sat baseline and apparently can't lay flat. I think a regional would be too stressful for myself and the patient in this situation, unless the patient can convince me otherwise. I would like to not have a breathing tube in her, but I feel like this case will head in that direction.

Other lines?
An arterial line will be helpful ,especially if she's gonna be tubed in the ICU.

NPO status?
All pregnant patients beyond 12 weeks are considered full stomachs. (My bad. Outdated info) Pre-induction A-line. RSI. Glidescope. If difficult proceed to airway algorithm.

Added nuggets
1) Hopefully the OB is decent at operating
2) Do the case during the day, maybe even in the morning so you can potentially have a colleague around to help
 
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SaltyDog said:
I love ya man, but this is false, outdated info. Pregnancy does not delay gastric emptying. Labor massively delays gastric emptying.
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I'll admit I hadn't looked up that information in a while so apologies to those on here who are in training. Gastric emptying is normal but LES tone is still reduced so it's something to keep in mind. I did stumble across something that said 18wks, regardless, this patient in question whether she had In-N-Out or not is getting an RSI
 
I think rsi is overrated in the pregnancy population. They do lmas for these gals routinely around the world. I would definitely do it for this patient though.

The AS was probably bad enough that they did an echo and was able to see it on a bmi 50 lady. Probably less than 1 cm area. I don't have the echo report though.

If she were my patient I would take her to the main OR instead of L&D and ask someone else to hang around. I would probably also do an awake a line and intubate with rsi etomidate double dose roc phenylephrine and make sure she's tanked up just like the rest of you. These covid guys desat fast but once the tube is in you should do okay. I would also leave the tube in and bring her to the icu as well. I think I'd place a central line to ensure I have good access and be really careful because I've seen patients just straight up die after an iatrogenic pneumothorax in the icu.

Their plan was to do preop a line and slowly dose up an epidural in the heart room with cardiac surgery standing by.
 
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GassYous said:
I think rsi is overrated in the pregnancy population. They do lmas for these gals routinely around the world. I would definitely do it for this patient though.

The AS was probably bad enough that they did an echo and was able to see it on a bmi 50 lady. Probably less than 1 cm area. I don't have the echo report though.

If she were my patient I would take her to the main OR instead of L&D and ask someone else to hang around. I would probably also do an awake a line and intubate with rsi etomidate double dose roc phenylephrine and make sure she's tanked up just like the rest of you. These covid guys desat fast but once the tube is in you should do okay. I would also leave the tube in and bring her to the icu as well. I think I'd place a central line to ensure I have good access and be really careful because I've seen patients just straight up die after an iatrogenic pneumothorax in the icu.

Their plan was to do preop a line and slowly dose up an epidural in the heart room with cardiac surgery standing by.
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I agree with @Arch Guillotti What's happening here where we need CT surgery on stand-by?
 
Didn’t think of ECMO but that seems kind of drastic.

Preop art line, careful induction, intubate, post op ventilation. She has real chance of crashing and burning postop after the operation is done. She needs time to settle out in the ICU.
 
GassYous said:
30 yo f with severe AS and BMI 52. Covid positive. Can't lay flat at good times and now is satting low 90s on nrb. What's your plan?

Not my case but a real one.
Click to expand...
You still didn't tell us why a 30 yo has severe AS. Is she just bicuspid and her valve degenerated really quickly? How's the rest of her echo? We're sure that she doesn't have any other abnormalities or wrongly attached plumbing that pedi cards needs to work up?

Also, her cardiac output demands given her whale-like morphology are really high. Should we be considering ballooning the valve pre-delivery?
 
No clue, case is from a different institution and I only know about it in passing. Just posted it to see what you guys would say.
 
Arch Guillotti said:
How bad is the AS?
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Sometimes I think all you do is close controversial threads. But this indeed is the question to ask, IS IT REALLY SEVERE??? at 30 years old?


GassYous said:
30 yo f with severe AS and BMI 52. Covid positive. Can't lay flat at good times and now is satting low 90s on nrb. What's your plan?

Not my case but a real one.
Click to expand...

Assuming no coronary artery disease, same plan as 30y F w/o AS. Her BMI doesn't even start with 6, what's the big deal?

I'm not even joking. I've done this case in residency. 40F G12p11 with severe AS. Just have a phenylephrine drip and let the mom see the baby. Ended up doing her SAVR a few weeks later. Good case to reference for perspective. Her myocardium is strong enough to go through 9 months of this, I bet you in those 9 months she's valsalva, yelled, and screamed more times than you can count. This is as simple case of AS. Be diligent in replacing blood if they lose too much, she will do fine.

CSE with phenylephrine drip, continuous spinal if you want to get fancy and want to titrate.

Edit: for some reason, i completely missed the pt had Covid. Sorry! To be fair, i've been trying to ignore covid for a while now hoping it would go away...
 
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dchz said:
Sometimes I think all you do is close controversial threads. But this indeed is the question to ask, IS IT REALLY SEVERE??? at 30 years old?




Assuming no coronary artery disease, same plan as 30y F w/o AS. Her BMI doesn't even start with 6, what's the big deal?

I'm not even joking. I've done this case in residency. 40F G12p11 with severe AS. Just have a phenylephrine drip and let the mom see the baby. Ended up doing her SAVR a few weeks later. Good case to reference for perspective. Her myocardium is strong enough to go through 9 months of this, I bet you in those 9 months she's valsalva, yelled, and screamed more times than you can count. This is as simple case of AS. Be diligent in replacing blood if they lose too much, she will do fine.

CSE with phenylephrine drip, continuous spinal if you want to get fancy and want to titrate.
Click to expand...

Problem is the covid. Can't lay back, crap o2 sat as it is, who knows if she has some crap in her lungs, myocarditis, clots, renal failure, etc. Just having covid alone in the obese population is bad news.
 
I thought the neighbors/in-laws helping out was an urban myth....but I have had 3 patients verify this process. Wow! How do you do it with your in-laws there?

Oh, the turkey baster method is not an urban myth either...go figure.

I'm with dchz about the bmi. We routinely have bmi 60-70's. At least 1 per month. I want to live where you guys live...or get smaller sliding doors to the hospital. And I agree with dchz for the approach for the case. I would add the art line and ask about syncope, angina symptoms. If she has those symptoms, then I would feel obligated for RSI general for severe AS pt scenario.

I had a buddy who took Bicitra b/c he was nauseated. It didn't help. Lol.
 
GassYous said:
Problem is the covid. Can't lay back, crap o2 sat as it is, who knows if she has some crap in her lungs, myocarditis, clots, renal failure, etc. Just having covid alone in the obese population is bad news.
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Exactly.
 
Everybody knows how to manage AS. The hard part is getting her to lie flat and avoid it turning into a cluster under the drapes. Postop may be very rocky as well even if you get by with neuraxial anesthesia.
 
dchz said:
Sometimes I think all you do is close controversial threads. But this indeed is the question to ask, IS IT REALLY SEVERE??? at 30 years old?




Assuming no coronary artery disease, same plan as 30y F w/o AS. Her BMI doesn't even start with 6, what's the big deal?

I'm not even joking. I've done this case in residency. 40F G12p11 with severe AS. Just have a phenylephrine drip and let the mom see the baby. Ended up doing her SAVR a few weeks later. Good case to reference for perspective. Her myocardium is strong enough to go through 9 months of this, I bet you in those 9 months she's valsalva, yelled, and screamed more times than you can count. This is as simple case of AS. Be diligent in replacing blood if they lose too much, she will do fine.

CSE with phenylephrine drip, continuous spinal if you want to get fancy and want to titrate.
Click to expand...
But you’re neglecting the pulmonary issues in the face of COVID and not being able to lay down. That’s a significant part for an awake and likely anxious patient
 
BobLoblaw78 said:
I thought the neighbors/in-laws helping out was an urban myth....but I have had 3 patients verify this process. Wow! How do you do it with your in-laws there?

Oh, the turkey baster method is not an urban myth either...go figure.

I'm with dchz about the bmi. We routinely have bmi 60-70's. At least 1 per month. I want to live where you guys live...or get smaller sliding doors to the hospital. And I agree with dchz for the approach for the case. I would add the art line and ask about syncope, angina symptoms. If she has those symptoms, then I would feel obligated for RSI general for severe AS pt scenario.

I had a buddy who took Bicitra b/c he was nauseated. It didn't help. Lol.
Click to expand...
Not surprised, since that's not really the indication of bicitra unless I'm wrong.
 
SaltyDog said:
I love ya man, but this is false, outdated info. Pregnancy does not delay gastric emptying. Labor massively delays gastric emptying.
Click to expand...

I learned 20 weeks progesterone effects which lower LES pressure and slightly increase aspiration risk. Gravid uterus definitely by upward displacement. But you are correct that labor is when gastric emptying is delayed..
 
GassYous said:
Problem is the covid. Can't lay back, crap o2 sat as it is, who knows if she has some crap in her lungs, myocarditis, clots, renal failure, etc. Just having covid alone in the obese population is bad news.
Click to expand...

Twiggidy said:
But you’re neglecting the pulmonary issues in the face of COVID and not being able to lay down. That’s a significant part for an awake and likely anxious patient
Click to expand...


Didn't see the covid section for some reason. My bad, ignore my previous reply.
 
dchz said:
Edit: for some reason, i completely missed the pt had Covid. Sorry! To be fair, i've been trying to ignore covid for a while now hoping it would go away...
Click to expand...

No worries, in this country you're in very good company
 
MirrorTodd said:
Not surprised, since that's not really the indication of bicitra unless I'm wrong.
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Yes. You are 100% correct.

I just thought it was a very stupid thing to do and thus funny. And now even funnier b/c I had to explain it.
 
Twiggidy said:
But you’re neglecting the pulmonary issues in the face of COVID and not being able to lay down. That’s a significant part for an awake and likely anxious patient
Click to expand...

it depends on how tenuous the respiratory status is.. if she is nearing intubation anyways and looks terrible, than i would intubate and ICU her..

if she is 94 on 6L NRB, but is just anxious and "feels" that she cant lay flat, I would bet I could finagle the bed and the surgeon to everyones satisfaction, give some nebs, possibly lasix, possibly bipap, possibly temporary LMA in combination with a spinal catheter and avoid intubating her which would likely worsen her resp situation
 
Arch Guillotti said:
Why CT surgery? Is it really that bad they are going to crash onto bypass and fully heparinize a pt. sickwith COVID and fully anticoagulate her post c/s?
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This patient's Covid is not that bad yet. Maybe the AS and all the volume that she's gonna get back post delivery possibly going into her already compromised lungs?
I was witness to a young 33 year old mom die in fellowship because CT surgery put in her chart that she couldn't be heparinized for a valve repair due to the fact that she would bleed out from her fresh Csection. They waited for her to have negative cultures and of course that wasn't gonna happen before she went into full blown acute heart failure and died. Those surgeons were practicing behind the times.
@Twiggidy, based on your experience, would above patient be a contraindication for full heparinization due to her Section?
 
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I can’t believe CT would replace the valve under these circumstances. ECMO maybe but I am hard pressed to believe that it would be needed in the OR. Would be nice if there were more concrete case details.
 
Hoya11 said:
it depends on how tenuous the respiratory status is.. if she is nearing intubation anyways and looks terrible, than i would intubate and ICU her..

if she is 94 on 6L NRB, but is just anxious and "feels" that she cant lay flat, I would bet I could finagle the bed and the surgeon to everyones satisfaction, give some nebs, possibly lasix, possibly bipap, possibly temporary LMA in combination with a spinal catheter and avoid intubating her which would likely worsen her resp situation
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I agree. I would be searching for every way to not ET her but based on what was presented I'm like 85% ETT
 
Hoya11 said:
it depends on how tenuous the respiratory status is.. if she is nearing intubation anyways and looks terrible, than i would intubate and ICU her..

if she is 94 on 6L NRB, but is just anxious and "feels" that she cant lay flat, I would bet I could finagle the bed and the surgeon to everyones satisfaction, give some nebs, possibly lasix, possibly bipap, possibly temporary LMA in combination with a spinal catheter and avoid intubating her which would likely worsen her resp situation
Click to expand...
An LMA for a c/s in a lady with a BMI of 52? No thanks.
 
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