OB Case

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That is what we were taught in residency ("optimize"). We were also given algorithms and guidelines as part of our training to do so. (Note that such guidelines take into account outcomes based on modern anesthesia care).

But it seems for preconception counseling for patients with MS, and for prosthetic valves, there are actually fairly decent guidelines put out by AHA. It would make a difference for the patient and for you if cardiologists used them to "optimize" patients.

If I know something and my colleague doesn't, I try in some way to educate them. Usually by including some reference in my A/P. And when they ask for my help and it is clear that they don't know something, and even possibly asked for the wrong thing, I figure it's probably a good thing that they called me.

For what it's worth, guidelines recommend anesthesiology consultation.
 
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By the way, this is a great case and should probably be presented at a multidisciplinary grand rounds, or used as a teaching case somehow. Be curious to know the outcome. Bet she does great. 😉
 
Ok here is what happened! Lots of great points/discussions/plans in this thread. Of course, the plan/situation evolved over several day and there were lots of back and forth discussions between different anesthesiology staff, the cardiologists, CCM, etc.

And yes, it was lovenox bridge, not warfarin, my mistake.

So after she was diuresed to the cardiologists satisfaction induction of labor began. After a few miso's were placed, heparin was held and an epidural was placed to attenuate the sympathetic stimulation of labor. Induction of labor proceeded and heparin drip was restarted (since it was unclear how long this induction in a prime parturient would take). She required only judicious IVF boluses and occasional phenylephrine touch ups early in labor. As labor progressed the epidural rate was increased and she became more hypotensive eventually requiring a phenylephrine drip. An arterial line was placed in the LDR at that time. Not long after, she started having variable decels with reasonable frequency. She stalled out around 6-7cm and OB decided they wanted to perform a C-section. At this point the epidural had been in place >24hrs and the block was a little one sided, though seemed to be responding to redoses. After long discussion, decision was made to perform the section under GA and not attempt to dose the epidural for the section. Heparin had been off 1-2hrs when the prospect of a section seemed imminent. She was induced with etomidate. She remained on phenylephrine drip and did not have any significant hypotension or other issues. Maintenance with prop/remi tiva to try and minimize atony. IM pitocin was used to minimize volume given. She did well and was extubated later that day, no excessive bleeding or blood products required.
 
Libertas said:
Ok here is what happened! Lots of great points/discussions/plans in this thread. Of course, the plan/situation evolved over several day and there were lots of back and forth discussions between different anesthesiology staff, the cardiologists, CCM, etc.

And yes, it was lovenox bridge, not warfarin, my mistake.

So after she was diuresed to the cardiologists satisfaction induction of labor began. After a few miso's were placed, heparin was held and an epidural was placed to attenuate the sympathetic stimulation of labor. Induction of labor proceeded and heparin drip was restarted (since it was unclear how long this induction in a prime parturient would take). She required only judicious IVF boluses and occasional phenylephrine touch ups early in labor. As labor progressed the epidural rate was increased and she became more hypotensive eventually requiring a phenylephrine drip. An arterial line was placed in the LDR at that time. Not long after, she started having variable decels with reasonable frequency. She stalled out around 6-7cm and OB decided they wanted to perform a C-section. At this point the epidural had been in place >24hrs and the block was a little one sided, though seemed to be responding to redoses. After long discussion, decision was made to perform the section under GA and not attempt to dose the epidural for the section. Heparin had been off 1-2hrs when the prospect of a section seemed imminent. She was induced with etomidate. She remained on phenylephrine drip and did not have any significant hypotension or other issues. Maintenance with prop/remi tiva to try and minimize atony. IM pitocin was used to minimize volume given. She did well and was extubated later that day, no excessive bleeding or blood products required.
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Well done.

Our imagination is often times more entertaining than reality.
 
urge said:
Well done.

Our imagination is often times more entertaining than reality.
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When planning for a complicated patient, surgeons tend to remember the 99% of cases when everything went well, while we have nightmares from the 1% past near misses. Obviously, the statistics are in favor of the former, but that's no excuse not to plan for the latter. This case wasn't the exception.

We are seen as Cassandras, until it hits the fan and everybody in the room suddenly needs diapers. I almost wish the latter would happen as frequently as 30-50 years ago.
 
sethco said:
As an aside, has anybody done a true "cardiac induction" in the past few years? You know high dose opiate/benzo only induction? I have never done one in residency, fellowship, or practice. Curious if anyone has
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I did opiate heavy cardiac inductions all the time during residency. One attending did only this type of induction and said the hemodynamics would remain rock solid....and only once did I see a patient not do well on induction (left main dz). His method was 2-4mg versed followed by 1-2mg fentanyl and muscle relaxant. About 70-80% of our cardiac attendings did mask induction and it was typically very smooth.
 
Planktonmd said:
The fact that they got away with this clunky plan unfortunately does not mean that this was the right plan!
But what matters is the result and they did not kill the patient so ... well done!
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Clunky plan? Seems like that was what the doctor recommended.

urge said:
I would put an a line along with the epidural. Titrate phenylephrine drip to desired bp.
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What a **** show.
All that back and forth. So many people involved for way too long.
Hindsight tells me, planned c/s would have been best approach. But the management was well done since your hands seemed to be forced somewhat.
But denifetly a job well done on the anesthesia part. We are not often able to convince surgeons that our plan is probably the best plan. They usually need to figure it out on their own.
However I have found that the older I get and the more experience I get, the more these surgeons listen to my suggestions. It takes a few bail outs on our part to get there with them.

PS FFP; lay off the internist. We could use more of them around here.
 
On that note, figure you all might appreciate this. From the internist.
Consider your frustrations with the rest of us as job security.

12485862_10208516673253769_5672471358855114354_o.jpg
 
Noyac said:
PS FFP; lay off the internist. We could use more of them around here.
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Are you out of your mind? They are worse than CRNAs. 😀

You don't need to defend internists from me: I wanted to become one, before I chose anesthesia. I would even take it as a second/third specialty, if it were only one more year and no clinic. What kills me is the analysis-paralysis, the mental masturbation, otherwise I have tremendous respect for good internists. They are hugely under-appreciated, even more than us. They just need somebody to tell them: you have x more minutes, chop-chop!
 
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FFP said:
Are you out of your mind? They are worse than CRNAs. 😀

You don't need to defend internists from me: I wanted to become one, before I chose anesthesia. I would even take it as a second/third specialty, if it were only one more year and no clinic. What kills me is the analysis-paralysis, the mental masturbation, otherwise I have tremendous respect for good internists. They are hugely under-appreciated, even more than us. They just need somebody to tell them: you have x more minutes, chop-chop!
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How did my name end up in that quote from Noyac?
 
That's me to a tee, I don't deny it (tendencies towards analysis/ paralysis).

I suppose everybody gets a little touchy when they feel like, "I Dont get no Respect."

Congratulations on the good outcome and allowing women with heart disease everywhere to continue to get pregnant safely. 😉


FFP said:
Are you out of your mind? They are worse than CRNAs. 😀

You don't need to defend internists from me: I wanted to become one, before I chose anesthesia. I would even take it as a second/third specialty, if it were only one more year and no clinic. What kills me is the analysis-paralysis, the mental masturbation, otherwise I have tremendous respect for good internists. They are hugely under-appreciated, even more than us. They just need somebody to tell them: you have x more minutes, chop-chop!
Click to expand...
 
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