OB case

[Noyac]

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30 yo female morbidly obese (BMI of 48) 35weeks pregnant with urosepsis. Currently hypotensive 80-90/40-50 in ICU on 10mcg norepinephrine and beginning to contract every 2 min. On Zosyn but the baby isn't tolerating anything well. OB calls for ceserean.
What's your plan?

 

[deleted171991]

Norepi bolus, prop/etomidate/ketamine/versed, sux, tube, or awake fiberoptic or Supreme LMA or similar (depending on mental status, airway and time constraints). A-line, central line, large bore IVs (all after induction if time is of essence), albumin, blood T&C.

Btw, this kind of patient should be intubated (unless she is an easy airway) and lined up in the ICU way before it could turn into a crash C-section. That's the job of a good intensivist.

 

[Arch Guillotti]

30 yo female morbidly obese (BMI of 48) 35weeks pregnant with urosepsis. Currently hypotensive 80-90/40-50 in ICU on 10mcg norepinephrine and beginning to contract every 2 min. On Zosyn but the baby isn't tolerating anything well. OB calls for ceserean.
What's your plan?

Art line.
No central line to do case.
Good IV access.
Stable induction of choice.
Intubate, awake fiber probably not necessary unless airway is horrendous.
Extubate if clinically indicated.

 

[BLADEMDA]

Norepi, prop/etomidate, sux, tube, or awake fiberoptic or Supreme LMA or similar (depending on airway and time). A-line, central line, large bore IVs, albumin, blood T&C.

As usual spot on. My approach is arterial line under U/S (guaranteed success in 2 minutes vs struggling in an obese, hypotensive patient via the blind technique), Central line followed by Glidescope assisted modified RSI (SUX her).

As for the induction agent one could argue for Ketafol (she is likely catecholamine depleted though) vs Etomidate (FPP would likely cover with IV steroids intra and postop) vs just Midazolam (will decrease SVR some even with low dose) and Fentanyl vs Scopalamine/Fentanyl.

Despite the risk to the Fetus I would have Vasopressin ready and available in the room ( 1 unit/ml) along with Epi (diluted in a syringe 4-8 ug/ml). I agree about the type and cross for PRBCs but I'm not sure about the use of Albumin here as that remains more controversial. I do agree that its nice to have a Colloid to rapidly increase intravascular volume on hand rather than utilize LR/Plasmalyte/Normosol crystalloids in this acute setting. But, as FFP is aware the benefits of Colloids isn't as clear cut these days

POINT: Should Intravenous Albumin Be Used for Volume Resuscitation in Severe Sepsis/Septic Shock? Yes

The Use of Fluids in Sepsis



Albumin Replacement in Patients with Severe Sepsis or Septic Shock ...
www.nejm.org/doi/full/10.1056/NEJMoa1305727
by P Caironi - ‎2014 - ‎Cited by 357 - ‎Related articles
Mar 18, 2014 - There is a convincing rationale for the potential advantages of albumin administration during severe sepsis.7 Albumin is the mainprotein responsible for plasma colloid osmotic pressure8; it acts as a carrier for several endogenous and exogenous compounds,9 with antioxidant and antiinflammatory properties, and as a ...

 

[deleted171991]

As usual spot on. My approach is arterial line under U/S (guaranteed success in 2 minutes vs struggling in an obese, hypotensive patient via the blind technique), Central line followed by Glidescope assisted modified RSI (SUX her).

As for the induction agent one could argue for Ketafol (she is likely catecholamine depleted though) vs Etomidate (FPP would likely cover with IV steroids intra and postop) vs just Midazolam (will decrease SVR some even with low dose) and Fentanyl vs Scopalamine/Fentanyl.

Despite the risk to the Fetus I would have Vasopressin ready and available in the room ( 1 unit/ml) along with Epi (diluted in a syringe 4-8 ug/ml). I agree about the type and cross for PRBCs but I'm not sure about the use of Albumin here as that remains more controversial. I do agree that its nice to have a Colloid to rapidly increase intravascular volume on hand rather than utilize LR/Plasmalyte/Normosol crystalloids in this acute setting. But, as FFP is aware the benefits of Colloids isn't as clear cut these days.

I wouldn't necessarily go for the steroid, not more than when I don't use etomidate. We still don't know how to even properly diagnose adrenal insufficiency in the ICU (except by its positive response to steroids), so I am not that impressed by the etomidate villain, especially in a p<0.05 world (should be p<0.001).

I do like to have albumin available in case of rapid bleeding. There is zero difference between crystalloids and colloids, except when one needs rapid intravascular volume (and viscosity) replacement and time is of essence. Blood is best, obviously. (We can have an entire thread about why some intensivists think that albumin is superior for fluid replacement in sepsis, given the modern glycocalyx model, despite no impact on outcomes.)

Also, this patient should have gotten a perc nephrostomy tube way before the situation degenerated. And an a-line and a central line (preferably cordis, or good additional peripheral IVs).

 

[dannyboy1]

Pre induction a-line. Prop, sux, glidescope tube. Assuming that pt already has central line as they are coming on norepi, but if not would not delay anymore to put one in (tracing is bad). Good peripheral access should be fine to get you though the case

 

[AdmiralChz]

Good discussion, I would argue for 2 large-bore IVs as well placed with the ultrasound Blade has brought into the room as well if required. This sounds like a crash c-section scenario so the baby (should) be out pretty quickly assuming G1, so I wouldn't be all that shy about needing vasopressin - we'll probably need it once the baby's out anyway.

Has anyone seen IV scopolamine recently? Our pharmacist claims it isn't even manufactured anymore, but I see it suggested enough that I wonder if that isn't the case.

 

[Noyac]

Also, this patient should have gotten a perc nephrostomy tube way before the situation degenerated. And an a-line and a central line (preferably cordis, or good additional peripheral IVs).

The PICC line is a triple lumen larger bore. So I would be ok with that and some good PIV's.
She came from outside facility who sent her home last night thinking she wasn't all that bad off.

 

[deleted171991]

The PICC line is a triple lumen larger bore. So I would be ok with that and some good PIV's.
She came from outside facility who sent her home last night thinking she wasn't all that bad off.

The PICC line is a joke. Good for pressors, but not much else. It's too long, so it behaves like a small peripheral. At least she had that.

I do realize that urosepsis can move really fast, but then I am an intensivist, which many of the community places lack after hours. If she needed a PICC for IV antibiotics, at 35 weeks, she should have stayed in the hospital and been monitored.

 

[Arch Guillotti]

My approach is arterial line under U/S (guaranteed success in 2 minutes vs struggling in an obese, hypotensive patient via the blind technique)

Until you don't get it in 2 minutes. Then it isn't guaranteed.

 

[Arch Guillotti]

This sounds like a crash c-section scenario

Perhaps this is a matter of semantics but I don't think this is a crash section.

It sounds urgent to me.

I consider ruptured uterus, bad abruption, etc a crash section.

 

[Noyac]

The PICC line is a joke. Good for pressors, but not much else. It's too long, so it behaves like a small peripheral. At least she had that.

I do realize that urosepsis can move really fast, but then I am an intensivist, which many of the community places lack after hours. If she needed a PICC for IV antibiotics, at 35 weeks, she should have stayed in the hospital and been monitored.

The PICC is for drips. It's fine for that. The PIV's are for volume.

Are you thinking she was sent home with a PICC?

 

[Ignatius J]

Just curious- what is the cause of urosepsis? If UTI, I understand. If it is ureteral occlusion from the uterus did they try a perc drain or ureteral stent?

 

[Arch Guillotti]

The PICC line is a joke.

Disagree. You may not be able to perform a volume resuscitation through it but it is guaranteed access.

 

[Noyac]

Just curious- what is the cause of urosepsis? If UTI, I understand. If it is ureteral occlusion from the uterus did they try a perc drain or ureteral stent?

Kidney but reportedly not obstructed. Therefore no drain.
I'm sort of staying away from the case for now.

 

[Ignatius J]

Kidney but reportedly not obstructed. Therefore no drain.
I'm sort of staying away from the case for now.

Gotcha, if it has to go it has to go. Lots of good volume and GETA.

Good discussion point may be neuraxial anesthesia in septic patients. Anyone with good recs?

 

[Libertas]

Good discussion point may be neuraxial anesthesia in septic patients. Anyone with good recs?

....don't do neuraxial on patients with norepi running?

 

[Arch Guillotti]

....don't do neuraxial on patients with norepi running?

If you have an art line, pressors in hand and the spinal is low dose then you probably can get away with it. Otherwise, no bueno.

 

[Noyac]

If you have an art line, pressors in hand and the spinal is low dose then you probably can get away with it. Otherwise, no bueno.

How low of a dose would you do?

 

[deleted59964]

no way in hell i'd do neuraxial for this.

art line, high flow nasal prongs, big peripheral iv, turn up norepi, prop, sux, tube.

 

[Arch Guillotti]

How low of a dose would you do?

Good question.

No hard or fast answer since it all depends on patient presentation.

Normal c/s dose is probably too much.

 

[Ignatius J]

....don't do neuraxial on patients with norepi running?

What about just a fever and mild tachycardia?

Any worries about sticking a needle in the IT space in the presence of bacteria in the bloodstream?

 

[Arch Guillotti]

What about just a fever and mild tachycardia?

Any worries about sticking a needle in the IT space in the presence of bacteria in the bloodstream?

No.

 

[Noyac]

What about just a fever and mild tachycardia?

Any worries about sticking a needle in the IT space in the presence of bacteria in the bloodstream?

If I had a good reason to do the spinal in a pt like you describe then I would do it.

 

[Noyac]

Good question.

No hard or fast answer since it all depends on patient presentation.

Normal c/s dose is probably too much.

My concerns would be that the dose would be too small and then I would have to induce GA and fight the hypotension I was trying to avoid with a smaller dose. But now it's compounded with GA.

 

[deleted171991]

Disagree. You may not be able to perform a volume resuscitation through it but it is guaranteed access.

Of course it's better than nothing. But my rant was directed at most non-anesthesiologists in love with PICCs and triple lumens in the ICU.

Unless the PICC is a high pressure/power injectable one, it sucks as a volume line. I would rather have two 18G PIVs and no central line, than a regular PICC/3-lumen and no PIVs. A good peripheral IV with a 2-inch catheter in a large vein can be safe enough even for prolonged pressor infusions.

 

[deleted171991]

Are you thinking she was sent home with a PICC?

Yeah, that's what I thought.

 

[deleted171991]

If you have an art line, pressors in hand and the spinal is low dose then you probably can get away with it. Otherwise, no bueno.

You assume the patient will respond to pressors even after your spinal. Kind of risky in a shocked patient.

I might play the game with a spinal catheter or slow titration over minutes through a spinal needle (have done zero of either), gauging BP drop and response to pressors, but not with a single-shot.

 

[anbuitachi]

Of course it's better than nothing. But my rant was directed at most non-anesthesiologists in love with PICCs and triple lumens in the ICU.

Unless the PICC is a high pressure/power injectable one, it sucks as a volume line. I would rather have two 18G PIVs and no central line, than a regular PICC/3-lumen and no PIVs. A good peripheral IV with a 2-inch catheter in a large vein can be safe enough even for prolonged pressor infusions.

For sure. PICC lines run slower than 1 20G IV so its god awful for resus.
But yea hopefully the patient already has arterial line since she is hypotensive on pressors. But if not, pre induction A line, large bore access (1 RIC + the PICC would be fine), etomidate, sux, pressor bolus. blood products ready. but it doens't sound too bad

 

[Noyac]

So everyone is fixated on IV access for a large blood loss and massive resuscitation. Anyone care to explain why this case will bleed so much more than a regular c/s?

 

[ElmerFudd]

30 yo female morbidly obese (BMI of 48) 35weeks pregnant with urosepsis. Currently hypotensive 80-90/40-50 in ICU on 10mcg norepinephrine and beginning to contract every 2 min. On Zosyn but the baby isn't tolerating anything well. OB calls for ceserean.
What's your plan?

Awake a-line and central line, general anesthetic.

30 yo female morbidly obese (BMI of 48) 35weeks pregnant with urosepsis. Currently hypotensive 80-90/40-50 in ICU on 10mcg norepinephrine and beginning to contract every 2 min. On Zosyn but the baby isn't tolerating anything well. OB calls for ceserean.
What's your plan?

A-line, central line, then general anesthesia with a tube. Induction with etomidate. Have levophed and vasopressin drips ready to go. Consider leaving patient intubated after case, depending on how "things" go. Keep the HCT 30 or above.

I'm also wondering how the sepsis would affect the uterus. Probably wouldn't help with the uterus involuting. Have hemorrhage meds handy too.

 

[wickedskillz]

put in an epidural and bolus it up slowly would be my choice, time permitting.

 

[GigiBuffon]

30 yo female morbidly obese (BMI of 48) 35weeks pregnant with urosepsis. Currently hypotensive 80-90/40-50 in ICU on 10mcg norepinephrine and beginning to contract every 2 min. On Zosyn but the baby isn't tolerating anything well. OB calls for ceserean.
What's your plan?

Definitely not neuraxial in a patient with septic shock, I won't even imagine chasing the hypotension and the predictable disaster. Baby is probably looking like crap at this point from hypoperfusion, and I bet this has been brewing for a few hours. She should have been lined up in the ICU, but in community hospitals she probably wouldn't be lined up...
If she isn't lined up, then she should get a pre-induction A-line, good IV access, and would get a RSI in the ramped up position with the glidescope and all airway tools available. Good chance she'll tank her pressures after induction regardless, so I'd go with Etomidate and Suxx to give me the best shot, with Vasopressin and other pressors ready. Wouldn't be surprised if she hemorrhaged, so have blood ready. Use BIS, decrease gas as soon as baby is out to help with BP and uterine contraction. Extubation... sure, if she looks phenomenal, which she won't.

 

[pgg]

So everyone is fixated on IV access for a large blood loss and massive resuscitation. Anyone care to explain why this case will bleed so much more than a regular c/s?

I think her risk of uterine atony is probably well above baseline because of the sepsis, but I'd be satisfied with my ordinary standard of good PIV access.

 

[deleted171991]

So everyone is fixated on IV access for a large blood loss and massive resuscitation. Anyone care to explain why this case will bleed so much more than a regular c/s?

She probably won't, unless she goes into DIC or shock liver (rare with urosepsis). She will just not tolerate bleeding as easily as a healthy patient.

Also pitocin can induce hypotension by decreasing SVR.

 

[anonperson]

The PICC line is a joke. Good for pressors, but not much else. It's too long, so it behaves like a small peripheral. At least she had that.

I do realize that urosepsis can move really fast, but then I am an intensivist, which many of the community places lack after hours. If she needed a PICC for IV antibiotics, at 35 weeks, she should have stayed in the hospital and been monitored.

She shouldn't have ever been sent home when first seen.

If they placed a PICC, I'm assuming they were treating for pyelonephritis. If so, she should have been admitted and observed when first seen. Where I trained, we were conservative and admitted and kept them until they defervesced for 24 hours, mainly to avoid the above scenario. Story is a bit odd in terms of their management.

In addition, PICCs in pregnant patients are though to be associated with an increased risk of infectious complication and try to avoid them. In a case like above, I question why they thought their manage was reasonable at the outside facility.

Holmgren C, Aagaard-Tillery KM, Silver RM, Porter TF, Varner M. Hyperemesis in
pregnancy: an evaluation of treatment strategies with maternal and neonatal
outcomes. Am J Obstet Gynecol. 2008 Jan;198(1):56.e1-4. doi:
10.1016/j.ajog.2007.06.004. PubMed PMID: 18166306.

Nuthalapaty FS, Beck MM, Mabie WC. Complications of central venous catheters
during pregnancy and postpartum: a case series. Am J Obstet Gynecol. 2009
Sep;201(3):311.e1-5. doi: 10.1016/j.ajog.2009.06.020. PubMed PMID: 19733284.

 

[GravelRider]

So everyone is fixated on IV access for a large blood loss and massive resuscitation. Anyone care to explain why this case will bleed so much more than a regular c/s?

I'm not sure the numbers, but I would guess she's at increased risk for DIC than your average parturient. Since she's already hypotensive, she won't tolerate moderate blood loss as well as a healthy patient. I would be satisfied with two good peripherals (18G) and the PICC for drips.

Also, what are her most recent labs? Is she in renal failure? What's her starting H/H? Acid/base status?

 

[vector2]

An 18g flows like 150-200ml/min tops, even under pressure. I'd want 16g+ or a cordis given risk of uterine atony and refractory hypotension.

 

[BLADEMDA]

I can see some of you haven't treated a lot of urosepsis; I have seen quite a few unfortunately and a central line is essential in this patient at some point. Could you do it after the baby is out? Yes. But, the hypotension will only get worse with the GA and the use of additional pressors is all but guaranteed.

Since I know that an arterial line and central line can be placed in under 4 minutes (total) with the use of u/s in experienced hands that's the route I would go here just like I've done countless times in my career.

 

[risnwb]

No.

I was taught to avoid spinal in bacteremic patients. Is this not a widely accepted practice? Or are you just willing to do spinal in this case because you believe the risk to the patient and fetus is greater with GA? Anyone know of any data regarding the outcomes of c sections done under general vs spinal?


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[facted]

I was taught to avoid spinal in bacteremic patients. Is this not a widely accepted practice? Or are you just willing to do spinal in this case because you believe the risk to the patient and fetus is greater with GA? Anyone know of any data regarding the outcomes of c sections done under general vs spi?

Bactatemia is not an absolute contraindication. Infection over the site definitely is. But with this patient being in dire straits, knocking out her sympathetics seems like a tough play.

 

[GravelRider]

I can see some of you haven't treated a lot of urosepsis; I have seen quite a few unfortunately and a central line is essential in this patient at some point. Could you do it after the baby is out? Yes. But, the hypotension will only get worse with the GA and the use of additional pressors is all but guaranteed.

Since I know that an arterial line and central line can be placed in under 4 minutes (total) with the use of u/s in experienced hands that's the route I would go here just like I've done countless times in my career.

Why would you place a central line in addition to the PICC? The PICC seems perfectly adequate to use for drips. I believe a post above said the PICC had three lumens. Are you placing a Cordis for volume?

 

[d9sccr]

Bactatemia is not an absolute contraindication. Infection over the site definitely is. But with this patient being in dire straits, knocking out her sympathetics seems like a tough play.

At our training institution it's a hard no, but I don't know what the official recs are. It was explained to me that we could potentially puncture the epidural veins and introduce bacteria to the CNS that way. The theoretical risk of doing that seems small, but with the introduction of VL, airway concerns are less an issue in these patients than they once used to be. I'd probably opt for GA unless I'm staring a known difficulty airway in the face

 

[deleted171991]

At our training institution it's a hard no, but I don't know what the official recs are. It was explained to me that we could potentially puncture the epidural veins and introduce bacteria to the CNS that way. The theoretical risk of doing that seems small, but with the introduction of VL, airway concerns are less an issue in these patients than they once used to be. I'd probably opt for GA unless I'm staring a known difficulty airway in the face

AFAIK, officially it's just a relative contraindication. The absolute contraindication is infection at the site/level of the injection.

 

[Noyac]

Why would you place a central line in addition to the PICC? The PICC seems perfectly adequate to use for drips. I believe a post above said the PICC had three lumens. Are you placing a Cordis for volume?

True. The PICC has a 16 & 20X2 g ports. It's an F'n central line.
And it was placed when she got to our facility, not from the outside facility that sent her home.

 

[Noyac]

The theoretical risk of doing that seems small, but with the introduction of VL, airway concerns are less an issue in these patients than they once used to be. I'd probably opt for GA unless I'm staring a known difficulty airway in the face

She is morbidly obese with pregnancy on top of that. They have volume resuscitated her with 5L IV fluids. Now her lips are swollen and her fingers look like little sausages.
What's the plan?

 

[Noyac]

More data:
WBC 22
Hgb 11.5
Hct 33.8
Plt 87
Lactate 2.6

Another question, what would you do about her labor? She is contracting. She is not intubate and following commands.

 

[waterbottle10]

So everyone is fixated on IV access for a large blood loss and massive resuscitation. Anyone care to explain why this case will bleed so much more than a regular c/s?

She's in septic/vasodilatory shock. Higher likelihood of bleed and less reserve.

True. The PICC has a 16 & 20X2 g ports. It's an F'n central line.
And it was placed when she got to our facility, not from the outside facility that sent her home.

Don't need another central line. Just need volume line so ricc is better.

She is morbidly obese with pregnancy on top of that. They have volume resuscitated her with 5L IV fluids. Now her lips are swollen and her fingers look like little sausages.
What's the plan?

Same plan just difficult tubing. Get backup equipment ready. Can do awake intubation if you think it will be that bad

 

[sevoflurane]

I'm a control freak in these situations.
Plan: GETA with adequate access. If my spider sense says VERY difficult AW, then give ENT a call and discuss your concerns...ie lips look like sausages.
I don't care if it's a CVL or a couple good PIVs. A-line is reasonable. Bilateral TAP at conclusion.
Neonatology in the room during delivery.
If she is obtunded... she keeps her tube for a little while.
Bed 45 Degrees, let the laryngeal edema subside.

 

[deleted171991]

FYI, most sacks of fluids (who self-extubate) in the ICU are still easily intubatable with a video laryngoscope.

Also, BMI 48 in a female doesn't necessarily mean difficult airway. It depends on where the excess BMI is located.

Ketamine is a great drug for inducing this kind of patient, unless the stomach could be full, in which case it's awake fun. Even then, learn how to do a gastric ultrasound.