Not your typical csection

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sevoflurane said:
and why does she want to cut her? FHR?
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This is the second time she has been in the ed in the past week, at her 1st visit enzymes and the tte were fine. Same thing at this visit. 1st set of enzymes are back and they are ok. Tte done by the cardiologist in ed with no wall motion abns, normal EF, normal valves. She was started on a nitro drip with slight improvement. Cardiologist says there's no point in further testing until she is delivered. This pregnancy has been normal, no pih, no diabetes.
 
Who was the jerk who got this lady pregnant. Couldn't they just have tied the tubes after the CABG. Reminds me of the time I had an Eisenmenger's patient in the C-section room which ended up disastrously.
 
sevoflurane said:
Bp, HR, Sats? (pregos & PE)
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Good thought, bp, sats are ok. Hr is in the 80's. She does not seem to be in any real distress. She is complaining of some chest discomfort but says it's not too bad. She is not sob, lungs are clear. Being a good ob, and a good cardiologist, they have already checked a gas and it looks ok.
 
cincincyreds said:
Who was the jerk who got this lady pregnant. Couldn't they just have tied the tubes after the CABG. Reminds me of the time I had an Eisenmenger's patient in the C-section room which ended up disastrously.
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:laugh::laugh:
 
cincincyreds said:
Who was the jerk who got this lady pregnant. Couldn't they just have tied the tubes after the CABG. Reminds me of the time I had an Eisenmenger's patient in the C-section room which ended up disastrously.
Click to expand...

I have one underlying theory when it comes to ob....guys will rarely if ever turn it down, anyone, any time, any place.
 
pd4emergence said:
30 year old lady, 37 wks, in ed for chest pain. Pt had a cabg for true 3 vessel disease 2 yrs ago. You get a call from the ob, she wants to section her.
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1) Ask cardiologist why patient has chest pain. One of the grafts went down? Re-stenosis of one vessel? New Vessel now blocked?

2) Use of Plavix? If not taking blood thinners (asa ok) then Neuraxial is fine

3) Use of Epidural (high block) has been shown to increase coronary perfusion. In deference to JET I'll only refer to a few studies:
http://circ.ahajournals.org/content/111/17/2165.full
http://www.ncbi.nlm.nih.gov/pubmed/19419349
http://www.ncbi.nlm.nih.gov/pubmed/18854796


The dermatomal level of anesthesia required for cesarean delivery is higher than that required for labor analgesia. A sensory block to the 10th thoracic dermatome is sufficient to achieve analgesia for labor, but for cesarean, the anesthetic level must be extended cephalad to at least the fourth thoracic dermatome to prevent nociceptive input from the peritoneal manipulation
 
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Why does she need a C section today???
Is it just because of the cardiac history that they want to section her electively or is there fetal distress?
If elective then we should wait, admit to ICU for monitoring, make sure she is beta blocked, maybe add a calcium channel blocker just in case there is some coronary spasm, repeat the enzymes in a few hours, repeat the EKG, and maybe repeat the echo as well.
If all remains stable then proceed with a spinal anesthetic as usual.
An a line might be a good idea pre-op.
I would not take a patient with active chest pain and known CAD to an elective c section based on some cardiologist's guess.
 
Planktonmd said:
Why does she need a C section today???
Is it just because of the cardiac history that they want to section her electively or is there fetal distress?
If elective then we should wait, admit to ICU for monitoring, make sure she is beta blocked, maybe add a calcium channel blocker just in case there is some coronary spasm, repeat the enzymes in a few hours, repeat the EKG, and maybe repeat the echo as well.
If all remains stable then proceed with a spinal anesthetic as usual.
An a line might be a good idea pre-op.
I would not take a patient with active chest pain and known CAD to an elective c section based on some cardiologist's guess.
Click to expand...

At my place there would be a note from the Cardiologist and Ob on the chart; in addition, I would have a conversation with both of them about our options here. Ob needs to know that cutting patient with active chest pain is a bad idea and should only happen if a true emergency. Cardiologist needs to answer options about a cath at some point for a look at the coronary vessels. Since I practice in a highly litigiouness environment you can bet your arse I will have the proper documentation before proceeding to the OR.
 
cincincyreds said:
Who was the jerk who got this lady pregnant. Couldn't they just have tied the tubes after the CABG. Reminds me of the time I had an Eisenmenger's patient in the C-section room which ended up disastrously.
Click to expand...

Now that's a case. Go ahead and post it. Here is a case report:

http://www.jmedicalcasereports.com/content/2/1/149


The following three classes of drugs targeting the correction of abnormalities in endothelial dysfunction have been approved recently for the treatment of PAH: (i) prostanoids; (ii) endothelin receptor antagonists; and (iii) phosphodiesterase-5 inhibitors. The efficacy and safety of these compounds have been confirmed in uncontrolled studies in patients with PAH associated with corrected and uncorrected congenital systemic-to-pulmonary shunts, as well as in patients with Eisenmenger's syndrome. One randomized controlled trial reported favourable short- and long-term outcomes of treatment with the orally active dual endothelin receptor antagonist bosentan in patients with Eisenmenger's syndrome.


Bosentan(boe sen' tan)

Last reviewed: September 1, 2010.

Warning

For female patients:
Do not take bosentan if you are pregnant or plan to become pregnant. Bosentan may harm the fetus. If you are sexually active and able to become pregnant, you should not begin taking bosentan until a pregnancy test has shown that you are not pregnant. You must use a reliable method of birth control and be tested for pregnancy every month during your treatment. Hormonal contraceptives (birth control pills, patches, rings,
 
I think, as a male, it speaks extremely poorly about my gender when these women, in all states of poor health, get pregnant. We've had the usual 300 pounders with the 150 lb. baby-daddy, or the ones with coarctation, pulm. htn, who are advised after first baby to not get pregnant, coming in within the next year, innocently stating "I didn't mean to get pregnant again. It just happened." :bang:

I often feel like I'm practicing veterinary anesthesia on the L&D floor sometimes.

When I'm president, anyone having a kid out of wedlock = automatic tubal ligation.
 
Planktonmd said:
Why does she need a C section today???
Is it just because of the cardiac history that they want to section her electively or is there fetal distress?
If elective then we should wait, admit to ICU for monitoring, make sure she is beta blocked, maybe add a calcium channel blocker just in case there is some coronary spasm, repeat the enzymes in a few hours, repeat the EKG, and maybe repeat the echo as well.
If all remains stable then proceed with a spinal anesthetic as usual.
An a line might be a good idea pre-op.
I would not take a patient with active chest pain and known CAD to an elective c section based on some cardiologist's guess.
Click to expand...


This was my thought at first until I talked with both the ob and cardiologist. This was their thought process. Pt was stable, sort of improved with the nitro. Cards guy is not sure why she is having chest pain but does not feel she is obviously ischemic on echo or ekg. She is on a beta blocker and her rates are pretty baseline for her when she has been in clinic before. They asked me "if she decompensates further what are we gonna do?" I think this is a reasonable question to ask. The answer is most likely a c section first.
 
pd4emergence said:
I have one underlying theory when it comes to ob....guys will rarely if ever turn it down, anyone, any time, any place.
Click to expand...

So true, I recently took care of a preggo pt w/spina bifida meningomyelocoele w/severe LE contractures that she couldn't open her legs to deliver vaginally. 😱 I'm still puzzled as to how she got pregnant
 
Why did she have a CABG at such a young age? Does she have a hematologist? I'd want more info on that before deciding to proceed with a regional technique. This is certainly a pt I'd want a full set of coags and plts on before I poke her w/a needle

As long as she's not actively having ischemia and her HR is under control she's optimized and if it's not the middle of the night it's as good a time as any to have a C-section. I'd opt for a slowly titrated epidural over a spinal, because it's more stable hemodynamically for a pt w/CAD.
 
pd4emergence said:
30 year old lady, 37 wks, in ed for chest pain. Pt had a cabg for true 3 vessel disease 2 yrs ago. You get a call from the ob, she wants to section her.
Click to expand...

Cut her. It's fine. If she codes you are one step ahead of the game.
 
ssmallz said:
Why did she have a CABG at such a young age? Does she have a hematologist? I'd want more info on that before deciding to proceed with a regional technique. This is certainly a pt I'd want a full set of coags and plts on before I poke her w/a needle

As long as she's not actively having ischemia and her HR is under control she's optimized and if it's not the middle of the night it's as good a time as any to have a C-section. I'd opt for a slowly titrated epidural over a spinal, because it's more stable hemodynamically for a pt w/CAD.
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Coags and plts were normal. No anticoagulants. I asked the ob about a previous hematologist w/u. It had been done and they did not find anything. Bad bad genes. Pt did not smoke and was not diabetic. I reviewed her cath report prior to cabg and it was true cad, not a thrombotic problem. Regardless, at this point I feel like all helpful data that can be obtained has been. It's time to make a decision. I personally feel like it time to proceed to the or. How do you do the case or hoe do you make your case for not doing it now? Fht's have been stable and the baby looks fine.
 
pd4emergence said:
Coags and plts were normal. No anticoagulants. I asked the ob about a previous hematologist w/u. It had been done and they did not find anything. Bad bad genes. Pt did not smoke and was not diabetic. I reviewed her cath report prior to cabg and it was true cad, not a thrombotic problem. Regardless, at this point I feel like all helpful data that can be obtained has been. It's time to make a decision. I personally feel like it time to proceed to the or. How do you do the case or hoe do you make your case for not doing it now? Fht's have been stable and the baby looks fine.
Click to expand...


Cards aware. OB/Gyn Aware. NL Labs. Neuraxial technique. Single shot spinal vs. CSE vs. Epidural. I'd do a CSE with a slow OB or a Single shot spinal for a fast one. Phenyephrine readily avail if needed. Vasopressin in my pocket as back-up if poop hits the fan.

In Academia they would do a CSE most likely. Careful titration of local ,etc. If I did a CSE patient would get 9 mg of Bup, 15 ug Fentanyl and Duramorph via the spinal portion then the catheter. I want my block to work in this case. Epidural catheters simply aren't as good as a solid spinal block.

I've got no issues with anyone giving a bit more Bup than above and threading the catheter for backup. I bet JET would simply give the Single shot Spinal of Bup 15 mg here.

That said, I'd try to minimize the hypotension here if possible.


http://www.anesthesia-analgesia.org/content/80/4/709

http://www.anesthesia-analgesia.org/content/109/5/1370.full
 
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Spinal, just like every other CS I do.

She has been revascularized. Cardiologist is happy. She has survived sex, and carried this watermelon around for a few months. She'll be just fine if my spinal takes her to 80/40 for a couple minutes.

But just in case, I'll be ready to open her chest if it hits the fan 😉
 
Here is what I did. Aline preop, two good ivs, nitro still running. I will be honest, I was worried about a spinal the accompanying abrupt hypotension. Plenty of time to slowly dose an epidural. So that's what I did. Dosed it with 2% lidocaine, railroad tracks, hr never above 100, bp's were not allowed to go below 110 or so. She had a great level after 15 cc's or so. Ob does her thing. Baby looks great, mom looks great. Cp better post op. Cath eventually done, grafts were open, no intervention.
 
For me, the decision tree is all about whether this patient is having ACS right now or not. For the sake of simplicity I'll leave out non-ACS causes of chest pain, like someone said PE, pneumonia, etc.

If it's STEMI, that's the trickiest possible situation but either cath or CS needs to happen emergently, and then the other to follow the first. I think "time is myocardium" applies here regardless of gravid status.

If it's NSTEMI, I think I'd like to optimize the hemodynamics as we've talked about, nitro as you are, then proceed urgently with CS under spinal/CSE/epidural.

If it's UA, you have a good amount of time proceed nonurgently with CS, would probably agree that someone with UA probably shouldn't go home or sit on L+D for hours-days laboring, but also doesn't need CS in the next 10 minutes.

In this case, it sounds like UA and so I would proceed nonurgently as you did, probably with an A-line, consider titrating in some metoprolol to 2-to-5mg increments to HR < 80 or so, avoiding fear/anxiety/pain with a heavier hand for IV sedatives/analgesics than with a scheduled elective CS.

I have some questions. Is she on aspirin? Is she beta-blocked? Why did she have a 3v CABG before age 30? MTHFR? Crazy dyslipidemia? Smoking?
 
For me a TTE with no regional wall motion abnormality puts my mind at ease about ischemia, assuming you trust your cardiologist is not a tool. She for sure has old TTE's to compare to and regional wall motion abnormalities are going to be more sensitive for ischemia than ECG findings, PA data, or enzymes(early on).

Still no idea why she has chest pain, I assume the PA(PE) and Aorta(dissection) look ok on the TTE.

Aline, Good PIV acess, Code Stuff ready in the room to ward off evil spirits, and then I'd do a spinal just like i do for every other C/S.
 
Magnus67 said:
For me a TTE with no regional wall motion abnormality puts my mind at ease about ischemia, assuming you trust your cardiologist is not a tool. She for sure has old TTE's to compare to and regional wall motion abnormalities are going to be more sensitive for ischemia than ECG findings, PA data, or enzymes(early on).

Still no idea why she has chest pain, I assume the PA(PE) and Aorta(dissection) look ok on the TTE.

Aline, Good PIV acess, Code Stuff ready in the room to ward off evil spirits, and then I'd do a spinal just like i do for every other C/S.
Click to expand...

You ever try doing a TTE on a gravid patient? It's nearly impossible for most...

They are all belly and boob... poor quality study comes to mind....

in my mind, this lady needs a section... it's not like you're going to send her for PCI at this point or send her for an exercise stress..

Manage it like she's a cardiac cripple with the potential for all sorts of badness

Have her chomp on an ASA (what the hell), titrate the metoprolol to make sure her HR is appropriate, morphine/NTG for pain and pop that LEP in. I'm not a crazy fan of A-lines saving lives so I wouldn't put one in but good IV access for sure. Dose it slowly and tell the OBs not to muck around once they get started...



drccw
 
drccw said:
You ever try doing a TTE on a gravid patient? It's nearly impossible for most...

They are all belly and boob... poor quality study comes to mind....
Click to expand...

I'm no sonographer, but we're not exactly looking for the interatrial septum or a gradient across the AoV. You don't need apical, you don't need subcostal.

If some nerd in the labs can eval the RV Fx on a friggin' mouse, and an OB can get an image of 4 chambers in the fetus, by god we can get a short axis of a term parturient to look at wall motion. I don't care if her EF is 45 or 55, I just want to make sure it's not 20.
 
Bertelman said:
I'm no sonographer, but we're not exactly looking for the interatrial septum or a gradient across the AoV. You don't need apical, you don't need subcostal.

If some nerd in the labs can eval the RV Fx on a friggin' mouse, and an OB can get an image of 4 chambers in the fetus, by god we can get a short axis of a term parturient to look at wall motion. I don't care if her EF is 45 or 55, I just want to make sure it's not 20.
Click to expand...

Agree with above. Again I mentioned if the cardiologist is not a complete tool he/she should be able to look at LV/RV function. In an otherwise healthy parturient if the ventricular function is anything less than good, i would start to worry.

My dream some day is to be able to do some "unofficial" TTE with a U/S machine we use for regional. Would be cool to show some ortho guy a crusty tight calcified aortic valve and say "this is why im worried"
 
Did you have a boggy uterus with the NTG running?

Just wondering. I've done/participated in a handful of cases of primary pulmonary htn with NTG running and ran into a boggy uterus requirering hemabate and ergots.
 
sevoflurane said:
Did you have a boggy uterus with the NTG running?

Just wondering. I've done/participated in a handful of cases of primary pulmonary htn with NTG running and ran into a boggy uterus requirering hemabate and ergots.
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I was wondering about that!
And if all of you (you, cardiologist, obstetrician...) agreed that the patient was not having ischemia then why did you keep the Nitro running?
 
Planktonmd said:
I was wondering about that!
And if all of you (you, cardiologist, obstetrician...) agreed that the patient was not having ischemia then why did you keep the Nitro running?
Click to expand...


It was everybody's best guess that she was not ischemic. Cp in a full term pregnant lady, with her history, I hedged my bet. She had had some improvement in her chest pain since coming to the ed. Whether or not it was the nitro, I didnt know. Post delivery she was a little boggy but got better after a short time with just pitocin. If I would have been pressed, I would have stopped the nitro. Even if she would have had some ischemia on echo or ekg, I don't think the management would have been any different (although the outcome may have been). She needed the section before any intervention could be undertaken.

As far as hemabate vs methergine, I don't know which one would have been better here. Probably hemabate. But that's just a guess.
 
pd4emergence said:
30 year old lady, 37 wks, in ed for chest pain. Pt had a cabg for true 3 vessel disease 2 yrs ago. You get a call from the ob, she wants to section her.
Click to expand...

You don't have a choice man.

Just do what you do.

Sitter up, spinal in,

ephedrine 20mg IV regardless of her starting BP and before you see the next,

lay her down and concentrate on

keeping her mean arterial BP above 80.

Btw I picked 80 out of the sky....I always try and keep MAP above 70 when doing a case where LOW BP is desired

so 80 for this lady and her comorbidities

looks good.
 
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