OB case

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GaseousClay

GaseousClay

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I think the best thing we do on this forum is post real cases and have discussions. It makes us all better as physicians and distracts from the doom and gloom a lot of people here try to bring upon us. Prob a good case to discuss for CA1-2 on their OB month.

38yo female g2p2 6 hours s/p repeat c-section that went uneventfully with 1.6ml of bupiv + 25mcg fentanyl + 100mcg duramorph spinal. Patient having some post partum bleeding slowly at first but increasing. concern for retained products vs uterine atony. Oxytocin being given, H/H back at 8.0/24 down from 10.1/31. coags/fibrinogen normal. We were called 2 hours after that 8/24. OB resident states we may have lost as much as 2L of blood since coming back to recovery and need to go back for stat D&C. Patient's blood pressure now is 90/60 HR 110-120. Patient looks pale and is feeling very dizzy. Has 1 20g IV and very poor venous access. OB attending requests another spinal as this procedure should be "very quick". Patient has eaten a bowl of soup, jello and orange juice. How would you proceed?
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So what I'm hearing is they've already lost as much as 4L of blood?? :laugh:

Probably get at least 4 units of ffp and prbc in the room, not quite ready to activate the massive transfusion protocol, but it might be coming soon. Start some albumin or blood (if available) running through the 20g asap if not already. Prefer pre-induction arterial line and a 9fr central venous catheter. Send a TEG asap if the equipment is available. Would avoid regional anesthesia with irreversible vasodilation and unknown/likely worsening coagulopathy/dic. Rapid sequence induction with ketamine versus awake techniques if airway looks unfavorable. Vasopressors prn.
 
A few issues:
#) Anesthetic choice: I would go for GETA, too much EBL to safely perform neuraxial and the last thing I want to deal with is an emergency airway (caused by worsening of her hypotension) while she's gushing blood all over the floor. Also, pt could possibly be developing DIC, don't want to stick needles in the spine without that info. MAC + paracervical block is also too risky in a pt "pale and lightheaded". You need to secure the airway. OB saying "Simple D&C" = automatically jinxed and the party is probably just getting started.

#) Access: doing a repeat C-section (repeat #1 i'm guessing) with a single 20g is risky IMO. I would have wanted at least one 18, preferably 2 (one for the oxytocin infusion, and one for bolusing pressors and volume resuscitation as those don't work as well if you're bolusing WITH oxytocin). I would first and foremost want to get better access before induction assuming I have the time to do it (pt not in hypovolemic shock, still conscious, and continued blood loss isn't excessively pressuring us to run to the OR stat). If no large bore peripherals can be found and urgent, put in a central line, if emergent consider IO. Start to volume resuscitate her immediately. Call for STAT blood to be ready and in the room (unless already typed and crossed), have the nurses check it ASAP to avoid wasting time. Hook up your blood set and as soon as RBCs are ready, start the transfusion. Make sure you're anesthesia tech's have a hot line set up for you and get Level 1 or some kind of rapid transfuser in the room (use pressure bags in the mean time). Consider giving tranexemic acid early, keep a close eye on the suction canister and be ready to active your massive transfusion protocol.

#) Monitoring: standard ASA + A-line. If she's 90/60 with 110-120s she's likely almost completely dry as from what i've been taught, these patients hold their pressures well until their HRs get into the 140s and then just completely bottom out. We're probably not far out from that given the recent 2L EBL. A-line before induction if time permits, otherwise alseep. Send off an ABG for baseline gases/H&H/lytes/base deficit. Get a TEG rolling to assess for coagulopathy. Could send off a CBC for platelets but that info would likely be reflected in the TEG. Continue with serial ABGs PRN to keep up with the on going bleeding.

#) Induction: pre-medicate with Famotidine, Bicitra, Metoclopramide. Assess the airway, most are a little more puffy from pregnancy related edema but not too bad. Assuming relatively normal airway anatomy, direct laryngoscopy with difficult airway equipment in the room would be reasonable (different blades, video laryngoscope, fiberoptic scope, intubating LMA, cricothyrotomy kit (not all laid out of course, just available)). Positing the patient as needed to optimize success (ramp or shoulder rolls as needed), thorough pre-oxygentation, +/- cricoid pressure, suction ready. RSI with etomidate or ketamine and succinylcholine keeping in mind hypovolemic patients & pregnant patients both require less anesthetic. The jello and OJ wouldn't phase me as these pt's are considered full stomach regardless. Have pressors ready within arms reach, set your BP monitor to go off every 1 min (unless a-line already in).

#) Maintence: I'd go for high opioid + N2O technique. No baby to worry about so you can be as liberal with your narcotic as needed. Avoid volatile anesthetics in this case as it'll only relax the uterus --> increased bleeding. I'm assuming she's already gotten Hemabate/Methergine from the OBs but keep these in the back of you mind and redose them PRN. She's been on an oxytocin infusion for a while so her uterine tone will be very poor.
 
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Good answer, i would skip this "Famotidine, Bicitra, Metoclopramide" and the etomidate and induce with midaz and ketamine or a touch of propofol depending on how she looks clinically.
 
This case is 6 hours in the making. She's not going to bleed to death in the next 15 minutes. Coags are normal so it's probably "just" blood loss, not anything really awful going on. As presented the OB's urgency is unwarranted. Get better IV access, transfuse her first, then GA.
 
nice replies

The OBs thought it was overkill to do general with preop a-line and central lines but they had their foot in their mouths after we started.

We actually did give bicitra,reglan,pepcid. IV access was terrible and the 20G was running really well so we induced with that after a preop a-line. airway exam was MP III, short fat neck , but good mouth opening so made a nice ramp with glidescope in room and proceeded with induction. Etomidate/Sux after good pre-ox. BP remained stable. Intubated with no issue (grade I with MAC 3). 9Fr Cordis placed. Versed/N2O maintenance. First labs back - Hgb 6.1/19, INR 2.1, fibrinogen 71. Case lasted over 7 hours of the OBs sitting around thinking of ways to stop the bleeding vs calling IR to try embolization. They initially thought it was retained products but even after pulling out what they thought was all of it there was continual oozing. Ended up giving 16pRBC, 8FFP, 4plts, 2cryo. Patient eventually got uterine artery embolization in IR, did well after a short 2 day stint in the ICU.
 
38 yo with 2 kids - 16 units of packed cells and 8 of ffp - take the damn uterus out
 
I would not have given any premeds other than some versed if needed.

I would not have placed a preinduction art line or central line either.

RSI geta, glidescope sounds like a good idea.

Get additional access after she is asleep, central if necessary. Art line if things aren't looking so hot. Resuscitate like crazy with the usual stuff as above.
 
Arch Guillotti said:
I would not have given any premeds other than some versed if needed.

I would not have placed a preinduction art line or central line either.

RSI geta, glidescope sounds like a good idea.

Get additional access after she is asleep, central if necessary. Art line if things aren't looking so hot. Resuscitate like crazy with the usual stuff as above.
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Completely agree. Perhaps ask the obstetricians to have a real surgeon (at least gyn/onc) in the operating room as well?:shrug:
 
Libertas said:
So what I'm hearing is they've already lost as much as 4L of blood?? :laugh:

Probably get at least 4 units of ffp and prbc in the room, not quite ready to activate the massive transfusion protocol, but it might be coming soon. Start some albumin or blood (if available) running through the 20g asap if not already. Prefer pre-induction arterial line and a 9fr central venous catheter. Send a TEG asap if the equipment is available. Would avoid regional anesthesia with irreversible vasodilation and unknown/likely worsening coagulopathy/dic. Rapid sequence induction with ketamine versus awake techniques if airway looks unfavorable. Vasopressors prn.
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??? So what WOULD give you cause to activate the massive transfusion protocol?

Our first step MTP is 4 units each of PRBC and FFP. You've already noted you would do that, so by definition at our place, we're into the MTP range. Better IV access and not even a snowball's chance of regional I agree with (not the OB's call for regional vs GA), although we would be +/- on the a-line, but that's the way it goes in private practice - and no TEG available, just the usual labs. We use propofol for almost everything, and would in this patient, but would decrease the dose. We would NOT start this case without all the first set of blood products in the room and already infusing, so would take the time we need to get a better IV or perhaps an introducer.

Faaaaaarrrrrrrr too long messing around in the OR and trying to decide what to do, even for academia, especially if they punted to IR for embolization. I would guess a lot of smaller hospitals wouldn't have the IR capability, so a hysterectomy would be the choice (and not a bad one at that). We used to see this crap all the time, but have gotten much more aggressive with MTP as well as early surgical management. They gyn/onc call is a great one to make if you have them available. They're generally far better surgeons, no offense to any OB's reading this thread.
 
Good case. I'll admit I didn't read all the comments but I did read a few of them.
My first step would be to slap the f*ck out of the OB attending for two reasons. One, for waiting so long and two, for mentioning a spinal.
Next, I would get good access. I would not induce with the plan of getting access after induction. I think this is a very bad idea. You may get away with it but why risk it? I have seen way too many previously "healthy" pts absolutely crump in this situation. Her BP is 90/60 with HR 120 so once you induce she will be 50/30 if your lucky. I have rarely seen healthy pts with massive blood loss much lower than 90's systolic when awake. They can maintain their BP surprisingly well until they are empty. You don't want to be dicking around looking for another IV or placing a central line in someone with no BP.
After good access, I would RSI with 200mcg of neo and a small dose of propofol (around 60mg giving it time to work). Remember, she is already dizzy, she won't remember anything and if she does then great, she survived. I'm sort of +/- on the versed but it won't too much since it's rather stable. You can always give more propofol once she is tubed and stable.
Now sit back and search ebay.
 
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Noyac said:
Good case. I'll admit I didn't read all the comments but I did read a few of them.
My first step would be to slap the f*ck out of the OB attending for two reasons. One, for waiting so long and two, for mentioning a spinal.
Next, I would get good access. I would not induce with the plan of getting access after induction. I think this is a very bad idea. You may get away with it but why risk it? I have seen way too many previously "healthy" pts absolutely crump in this situation. You don't want to be dicking around looking for another IV or placing a central line in someone with no BP.
After good access, I would RSI with a small dose of propofol (around 60mg giving it time to work). Remember, she is already dizzy, she won't remember anything and if she does then great, she survived. I'm sort of +/- on the versed but it won't too much since it's rather stable. You can always give more propofol once she is tubed and stable.
Now sit back and search ebay.
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She has very crappy access so assume you fish around for an IV for a while and can't get it. Are you going to do an awake central line on a (presumably) fat lady with a "short fat neck" who is bleeding like this?
 
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Arch Guillotti said:
She has very crappy access so assume you fish around for an IV for a while and can't get it. Are you going to do an awake central line on a (presumably) fat lady with a "short fat neck" who is bleeding like this?
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Sure, why not? You could kill her if you don't.
And I don't care how obese she is. That's no reason to do asleep. We put CVP in awake whales all the time that aren't having surgery. Why would she be any different? Plus, I can use this time to give some blood. But I wouldn't hold the case up to give blood like some here would. That's stupid IMO. With that 20g your gonna put it in her slower than it's pouring out of her uterus. What sense does that make?
 
Noyac said:
Sure, why not? You could kill her if you don't.
And I don't care how obese she is. That's no reason to do asleep. We put CVP in awake whales all the time that aren't having surgery. Why would she be any different? Plus, I can use this time to give some blood. But I wouldn't hold the case up to give blood like some here would. That's stupid IMO. With that 20g your gonna put it in her slower than it's pouring out of her uterus. What sense does that make?
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I wouldn't hold up the case either.

Given the information presented I feel that I can safely put her to sleep with the existing access, that's all.
 
Arch Guillotti said:
I wouldn't hold up the case either.

Given the information presented I feel that I can safely put her to sleep with the existing access, that's all.
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I'm sure you can. I just wouldn't be comfortable attempting it that way.

Plus, not to bag on you cuz you are an experienced anesthesiologist and can make your own choices but there are younger folks here with less experience that would get into a world of trouble doing it this way.
 
I am not sure if you guys are just really understanding or if it happens so much that you no longer bitch about it, but what the hell were they doing with the lady as she was bleeding for 2 hrs and becoming hypotensive. She should have come to you guys with better access and products already hanging (I wonder if her access was ****ty just because she was trying to bleed to death). Interesting case though. Maybe she was adamant about wanting more kids, but that doesn't explain why they would dick around for 7 hrs before going to IR. That is probably the surgeon in me talking though.
 
dpmd said:
I am not sure if you guys are just really understanding or if it happens so much that you no longer bitch about it, but what the hell were they doing with the lady as she was bleeding for 2 hrs and becoming hypotensive. She should have come to you guys with better access and products already hanging (I wonder if her access was ****** just because she was trying to bleed to death). Interesting case though. Maybe she was adamant about wanting more kids, but that doesn't explain why they would dick around for 7 hrs before going to IR. That is probably the surgeon in me talking though.
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You are absolutely right. But in cases like this, as anesthesiologists, we do what is necessary, we take care of the pt and handle the inadequacies of our colleagues after the fact.
 
IO, IO, IO. If you can't get good access, just stick a line in the bone. Why fiddle around sticking the patient over and over or performing an awake central line.
 
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loveumms said:
IO, IO, IO. If you can't get good access, just stick a line in the bone. Why fiddle around sticking the patient over and over or performing an awake central line.
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What in the world is wrong with an awake central line? Personally I would much prefer this to an IO if I were a pt. It I've never had an IO, Not for lack of trying tho.
 
We also have the good ol RICC line. I know she's difficult but that never really stops us.
 
I'm with Noyac on this. This case has been brewing for six hours. Her vitals are fine. She's not even a cold or coagulopathic trauma patient coming in from the street. There's no reason to rush into the OR. She has a 20g IV because the only person who's tried to get another IV was the L&D nurse who gave up after one or two sticks because Facebook wasn't going to status-update itself.

Resuscitate/transfuse first (you can start with the 20g), get better access, then induce.
 
I'm with PGG on getting better access, and not inducing until you've caught up somewhat with products. Like he said, 6 hours of oozing, and all of a sudden we need to stat induce a symptomatic nearly exsanguinated patient? I would understand more if blood were pouring out, but that doesn't appear to be the case. I'm not seeing the great benefit of rushing to induce.

If you are going to induce a pt w hr 120s and symptomatic hypotension, awake a-line if there's time. If transfused and more stable, maybe not necessary.

Agree with awake central volume line if no good access.
 
In case some are misreading my approach, I would not delay. I would get better access and proceed. You may not see overt signs of bleeding but it still can be there, contained in the uterus.
My plan again: get good access and go to town.
 
Another note: just because OB delayed for 6 hrs doesn't mean we can. Get on with the case now.
 
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Since the 20 G IV was running well and she was not gushing out blood with acceptable hemodynamics, I would go ahead and put her to sleep (with gentle dose of induction agents). Central lines and/or big IVs become so much easier once she is off to sleep. I would be hesitant to put in a big cordis in an awake postpartum/fat patient who just ate.
 
Mac4 said:
Since the 20 G IV was running well and she was not gushing out blood with acceptable hemodynamics, I would go ahead and put her to sleep (with gentle dose of induction agents). Central lines and/or big IVs become so much easier once she is off to sleep. I would be hesitant to put in a big cordis in an awake postpartum/fat patient who just ate.
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I agree that this can be done and would work fine more times than not. I'm just being the devils advocate a bit here. A few things that make me take note with this case are:
1)hemodynamics- they may seem ok on the surface but like I said before, young previously healthy pts will maintain their BP quite well until the moment they crash right in front of your eyes and everyone looks around with amazement. Her HR of 120 tells me she is nearly completely compensated and may have no more reserve. But she may, that's your call.
2) Access- yes it is much easier to obtain access with the pt asleep as long as you aren't coding her at the same time.
3)not sure what the problem is with putting a line in someone "awake" that just ate.
 
Arch, you'll be glad to know that I had a case tonight very similar to this one and I did it your way.

But I could see huge veins in her hand and arm prior to induction so I wasn't worried about access.

My poor pt spent a day at an outside Hosp bleeding and subsequently becoming infected from retained products after a pharmacologically induced abortion. BP 90/50, HR 113, h/h-10/30 with 1L LR given over 24 hrs. Otherwise healthy.
Slam dunk of a case but one you need to be careful with nonetheless.
 
why would someone aspirate during central line placement? even if they happened to vomit from hypovolemia/hypotension, they should have intact airway reflexes. unless you were sedating them, which I would not recommend.
 
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Pt. is pale and dizzy with a short fat neck who just ate and drank a bunch. Put her in some trendelenburg with a drape all over her face and go poking around in her neck. I put the chance of puking all over the place pretty high.
 
I understand the concern, but people don't just go around randomly barfing all over the place while awake.

But say that they do- the awake patient, especially the awake patient in Tendelenburg, will have the airway reflexes to prevent any puke from making its way into the trachea. Plus, gravity.
 
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Hawaiian Bruin said:
I understand the concern, but people don't just go around randomly barfing all over the place while awake.

But say that they do- the awake patient, especially the awake patient in Tendelenburg, will have the airway reflexes to prevent any puke from making its way into the trachea. Plus, gravity.
Click to expand...

Barfing and pregnancy go hand in hand.
 
Arch Guillotti said:
Pt. is pale and dizzy with a short fat neck who just ate and drank a bunch. Put her in some trendelenburg with a drape all over her face and go poking around in her neck. I put the chance of puking all over the place pretty high.
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I don't.
And if she is dizzy from hypotension then t-berg should help.
 
Ok everyone, there are inherent risks with everything we do. The goal is to minimize these risks and to be ready to deal with them when they occur. Everyone has their own ideas of the risks at hand and how "they" prefer to deal with them. The reason we do a lot of things the way we do is because of past experiences. You will often see many different approaches as in this thread. I totally disagree with Arch here but that's ok. My experiences tell me to do this case one way. His tell him another way. Neither is wrong, "until something goes awry."
 
Now, back to the case. arch, you just described a hypotensive unstable pt with a full stomach and a short fat neck that has been bleeding out for the past 6 hrs with a mediocre 20g PIV. ARE YOU STILL GONNA GO WITH YOUR PLAN?
 
Noyac said:
Now, back to the case. arch, you just described a hypotensive unstable pt with a full stomach and a short fat neck that has been bleeding out for the past 6 hrs with a mediocre 20g PIV. ARE YOU STILL GONNA GO WITH YOUR PLAN?
Click to expand...

I would.

I mean, really, think yourself in the OB PACU and have to take this lady to OR. Do you really put her head down and try to put in a huge cordis? I'd secure her airway first.
 
Why do you need to secure the airway before putting in a central line? Are you assuming that you would give sedation for it? The patient can't aspirate if they are maintaining their airway reflexes.

I would assure reliable IV access before induction whether that be peripherals, intraosseous, central, or whatever.
 
Mac4 said:
I would.

I mean, really, think yourself in the OB PACU and have to take this lady to OR. Do you really put her head down and try to put in a huge cordis? I'd secure her airway first.
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Who in the world is talking about a "huge cordis"? I sure am not. I'm gonna place a good PIV. NOBODY IN THEIR RIGHT MIND WOULD BE PLACING A CORDIS IN THIS PT.
 
Noyac said:
Who in the world is talking about a "huge cordis"? I sure am not. I'm gonna place a good PIV. NOBODY IN THEIR RIGHT MIND WOULD BE PLACING A CORDIS IN THIS PT.
Click to expand...

Then we are on the same page. If she has a good IV, put her to sleep.
 
Also, according to the California Maternal Quality Care Collaborative: Hemorrhage task force .... (like I said before regarding Gyn/Onc)......

This .....
 

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