OB Epidurals

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    Pt has platelet count of 95,000. Epidural is requested. No signs of pre-eclampsia. Should the epidural be performed?

    Probably. Depends. Need more info.

    We talked about platelets and OB anes in this thread a while ago.
     
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      What are u going to do if you have a known difficult AW with history of impossible intubation (before pregnancy), Pre-eclampsia, help syndrome with platelets that are 25k. Cardiac h/o MS with pulm htn. She is 120 kgs bmi of 55. She presents for stat c/s for twin delivery. Full stomach.

      It's 2:30 am and you are the only gas doc in house.

      OB says we need to cut asap.
       

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        What are u going to do if you have a known difficult AW with history of impossible intubation (before pregnancy), Pre-eclampsia, help syndrome with platelets that are 25k. Cardiac h/o MS with pulm htn. She is 120 kgs bmi of 55. She presents for stat c/s for twin delivery. Full stomach.

        It's 2:30 am and you are the only gas doc in house.

        OB says we need to cut asap.

        Oral boards are coming up...!

        ;)
         

        fakin' the funk

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          What are u going to do if you have a known difficult AW with history of impossible intubation (before pregnancy), Pre-eclampsia, help syndrome with platelets that are 25k. Cardiac h/o MS with pulm htn. She is 120 kgs bmi of 55. She presents for stat c/s for twin delivery. Full stomach.

          It's 2:30 am and you are the only gas doc in house.

          OB says we need to cut asap.

          First question: what's the indication for "stat" CS? If FHR is 40 independent of ctx, we go now. If she's just having "arrest of descent" or nonreassuring FWB, we have time. Lots of times they just say STAT to get people off their *sses.

          OK. O2 on the pt at all times. If there's any help available, I call for it. Due to coagulopathy, likely technical difficulty of spinal, and urgency/emergency and it has to be a general anesthetic. LUD. Huge ramp. 2 big PIV's. T+C for 4 RBC, 4 FFP, 2 PLTpheresis with the intent to xfuse 1 PLT pack ASAP. A-line can wait if NIBP works at all. I would get methylergonovine in the room now. Not sure about Hemabate in this situation with the pHTN.

          If we have 5-10 min, awake FOB with atomized 4% lido in oropharynx and huffed by pt. If we don't, prep and drape and with ramp and preox, RSI with CP, etomidate, sux, alfentanil, 1st look is with Glidescope, if no dice I place intubating LMA, confirm etCO2, try to keep cricoid on, and tell them to cut. When FOB arrives, use to place ETT. Then OG tube. No nitrous. Amnestic dose sevo and lots of narcotics to avoid hyperdynamic circulation. Watch for Afib and autotransfusion.

          Now I may have a couple of minutes to place A-line. Expect a large bloodloss and atony and a long case; may need hysterectomy. Stay ahead with products. Serial ABG's as needed. Low threshhold to call for TEE if CO is saggy and it's available.
           

          Idiopathic

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            First question: what's the indication for "stat" CS? If FHR is 40 independent of ctx, we go now. If she's just having "arrest of descent" or nonreassuring FWB, we have time. Lots of times they just say STAT to get people off their *sses.

            OK. O2 on the pt at all times. If there's any help available, I call for it. Due to coagulopathy, likely technical difficulty of spinal, and urgency/emergency and it has to be a general anesthetic. LUD. Huge ramp. 2 big PIV's. T+C for 4 RBC, 4 FFP, 2 PLTpheresis with the intent to xfuse 1 PLT pack ASAP. A-line can wait if NIBP works at all. I would get methylergonovine in the room now. Not sure about Hemabate in this situation with the pHTN.

            If we have 5-10 min, awake FOB with atomized 4% lido in oropharynx and huffed by pt. If we don't, prep and drape and with ramp and preox, RSI with CP, etomidate, sux, alfentanil, 1st look is with Glidescope, if no dice I place intubating LMA, confirm etCO2, try to keep cricoid on, and tell them to cut. When FOB arrives, use to place ETT. Then OG tube. No nitrous. Amnestic dose sevo and lots of narcotics to avoid hyperdynamic circulation. Watch for Afib and autotransfusion.

            Now I may have a couple of minutes to place A-line. Expect a large bloodloss and atony and a long case; may need hysterectomy. Stay ahead with products. Serial ABG's as needed. Low threshhold to call for TEE if CO is saggy and it's available.

            why no nitrous.
             

            Jeff05

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            1. Attending Physician
              What are u going to do if you have a known difficult AW with history of impossible intubation (before pregnancy), Pre-eclampsia, help syndrome with platelets that are 25k. Cardiac h/o MS with pulm htn. She is 120 kgs bmi of 55. She presents for stat c/s for twin delivery. Full stomach.

              It's 2:30 am and you are the only gas doc in house.

              OB says we need to cut asap.

              Great post to elicit thought.

              #1. do NOT put her to sleep as you will not be able to adequately ventilate her with an LMA. maybe with a supreme,but you can't intubate through that.
              #2. this is an awake FO. i would have her sitting up and intubate like ENTs do. i've been going this and it is SOOOO much better and faster than our usual way.
              #3. aline, tons of fentanyl and a touch of gas - avoid drops in preload or tachycardia
              #4. Do not extubate postop. CTICU intubated to watch for pulm edema. Consider keeping intubated and doing valve if looking ok a day or two after.

              bottom line - mother's life is more important than baby's. you will kill her in two ways if she goes to sleep without an airway. 1. almost immediate hypoxia 2. RV failure secondary to bump in PAP as a result of hypoxia/hypercarbia.
               
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              proman

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                Consider keeping intubated and doing valve if looking ok a day or two after.

                No way would a cardiac surgeon do a CPB case in the immediate post-delivery period. Need to know the MV gradient, measurements etc. Ballon mitral valvuloplasty would be the first step. If she's survived the third trimester she'll probably survive the post-partum period.
                 

                BLADEMDA

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                  First question: what's the indication for "stat" CS? If FHR is 40 independent of ctx, we go now. If she's just having "arrest of descent" or nonreassuring FWB, we have time. Lots of times they just say STAT to get people off their *sses.

                  OK. O2 on the pt at all times. If there's any help available, I call for it. Due to coagulopathy, likely technical difficulty of spinal, and urgency/emergency and it has to be a general anesthetic. LUD. Huge ramp. 2 big PIV's. T+C for 4 RBC, 4 FFP, 2 PLTpheresis with the intent to xfuse 1 PLT pack ASAP. A-line can wait if NIBP works at all. I would get methylergonovine in the room now. Not sure about Hemabate in this situation with the pHTN.

                  If we have 5-10 min, awake FOB with atomized 4% lido in oropharynx and huffed by pt. If we don't, prep and drape and with ramp and preox, RSI with CP, etomidate, sux, alfentanil, 1st look is with Glidescope, if no dice I place intubating LMA, confirm etCO2, try to keep cricoid on, and tell them to cut. When FOB arrives, use to place ETT. Then OG tube. No nitrous. Amnestic dose sevo and lots of narcotics to avoid hyperdynamic circulation. Watch for Afib and autotransfusion.

                  Now I may have a couple of minutes to place A-line. Expect a large bloodloss and atony and a long case; may need hysterectomy. Stay ahead with products. Serial ABG's as needed. Low threshhold to call for TEE if CO is saggy and it's available.


                  You Pass this Oral Exam. But, Technical difficulty doing a spinal? 120 kg isn't that big these days. You can always use a long 22G whitacre needle in this emergency case. Platelets are so low that transfusion is likely anyway so if you have time (which the examiners won't give you) then transfuse the platelets and do a spinal.

                  My experience is that these 120Kg patients rarely get a H/A with any size non-cutting needle.

                  I do prefer the A-line if possible and 2 large bore IVs or Central Line. I would expect questions about the use of Ketamine (low dose), BIS vs. ET vapor and your threshold for Hgb transfusion.
                   

                  pillowhead

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                    No way would a cardiac surgeon do a CPB case in the immediate post-delivery period. Need to know the MV gradient, measurements etc. Ballon mitral valvuloplasty would be the first step. If she's survived the third trimester she'll probably survive the post-partum period.

                    We did a c-section in our cardiac rooms once so the patient could go straight into valve replacement right after the c section. Damned if i can't remember which valve though.
                     

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                      FWIW I think RSI is a kill error for someone with a known impossible airway even before pregnancy.

                      There's obviously no good option here, as with most oral board scenarios. You have 1) regional with low platelet count, 2) FOI and GA, or 3) local by surgeon with ketamine/nitrous/midaz/whatever.

                      Problems with regional: obv risk of hematoma, and venodilation in a preload dependent MS pt. No thanks.

                      Problems with FOI: time consuming. Still probably your best bet all things considered. Would go with this as plan A. Etomidate/sux once tube goes in, maintain with midaz/whiff of vapor/possibly remi if I could get it. Avoiding nitrous is probably reasonable though I suspect its effect on right heart function would probably be negligible in this pt with pulmonary venous hypertension and a compensated RV.

                      If no time for FOI: then it's time for lots of local on the field with your sedation recipe. You could accomplish this with: midaz (reversible, little resp depression when used alone), plus maybe some ketamine (though watch for airway secretions since glyco isn't an option in MS, and titrate carefully to avoid tachycardia).

                      I would also use the circle system in this scenario to give 100% O2 and more accurately keep tabs on Vt and minute ventilation. EtCO2 then becomes a bootlegged cardiac output trend monitor. I may even consider something like 25-30% nitrous if things got dicey, which I highly doubt would increase PVR any more than pain will.
                       

                      Arch Guillotti

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                        What are u going to do if you have a known difficult AW with history of impossible intubation (before pregnancy), Pre-eclampsia, help syndrome with platelets that are 25k. Cardiac h/o MS with pulm htn. She is 120 kgs bmi of 55. She presents for stat c/s for twin delivery. Full stomach.

                        It's 2:30 am and you are the only gas doc in house.

                        OB says we need to cut asap.

                        Hopefully none of us will ever be in this scenario because it is a no-win situation.

                        I would not put her to sleep based on her history of impossible intubation unless the history of intubation can be quantified. I think this is a kill error if you rush into it.
                         
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                        1. Attending Physician
                          Spinal catheter with platelets is exactly what I would do. Benefit>>>>>risk.

                          I'm not going to waste time with an edematous AW that has a history of failure + MS/pulm htn/hyperdynamic heart is not a good combo.

                          Frequent neuro checks post op. You have time if you do get a hematoma.

                          Best option IMHO.
                           

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                            If you use nitrous, ketamine, etc.... The examiner is going to make her aspirate which will cause hypoxia and tachycardia which will elevate pulm. pressure and increase the pressure gradient across the MV. This will cause your patient to go into heart failure, pulm edema and death. Don't burn bridges on the exam. Keep 'em breathing with a protected aw if you have the option.
                             
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                            Idiopathic

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                              If you use nitrous, ketamine, etc.... The examiner is going to make her aspirate which will cause hypoxia and tachycardia which will elevate pulm. pressure and increase the pressure gradient across the MV. This will cause your patient to go into heart failure, pulm edema and death. Don't burn bridges on the exam. Keep 'em breathing with a protected aw if you have the option.

                              if you do the spinal the case will turn into a blood bath and you will have to intubate to resuscitate. no way to win this one, just cant ever stop answering questions ;)

                              or you wont be able to get the spinal, or you will get a high spinal....at least this is what i anticipate
                               

                              Hawaiian Bruin

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                                Sevo, your points are well taken, and I agree that for the immediate intraop period, the reward of regional may well outweigh the risk of hematoma.

                                That said, I think the postop challenges this patient will face will be much more easily managed intubated in an ICU. She'll need transfusions, probably with a substantial volume. She'll autotransfuse from her uterus. This on top of the restrictive lung disease that goes with her BMI means postop respiratory problems are likely, not just possible.

                                So I'd rather intubate in a semi-controlled fashion in the OR rather than frantically in postpartum/ICU after she goes into flash pulmonary edema after her 3rd bag of platelets and 2nd PRBCs, when her airway is only going to be more edematous and the scene chaotic. Then keep her intubated for the next 2-3 days while her volume shifts sort themselves out.

                                This is a good theoretical case with lots to think about.
                                 

                                Arch Guillotti

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                                  if you do the spinal the case will turn into a blood bath and you will have to intubate to resuscitate. no way to win this one, just cant ever stop answering questions ;)

                                  or you wont be able to get the spinal, or you will get a high spinal....at least this is what i anticipate

                                  yeah, we could go round in circles all day long with these scenarios. You will have difficult scenarios with the oral exam but if you pick a decent plan, execute the plan (not the patient), and can adapt then you can come through a lose-lose situation relatively unscathed.
                                   

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                                    Sevo, your points are well taken, and I agree that for the immediate intraop period, the reward of regional may well outweigh the risk of hematoma.

                                    That said, I think the postop challenges this patient will face will be much more easily managed intubated in an ICU. She'll need transfusions, probably with a substantial volume. She'll autotransfuse from her uterus. This on top of the restrictive lung disease that goes with her BMI means postop respiratory problems are likely, not just possible.

                                    So I'd rather intubate in a semi-controlled fashion in the OR rather than frantically in postpartum/ICU after she goes into flash pulmonary edema after her 3rd bag of platelets and 2nd PRBCs, when her airway is only going to be more edematous and the scene chaotic. Then keep her intubated for the next 2-3 days while her volume shifts sort themselves out.

                                    This is a good theoretical case with lots to think about.

                                    I agree with you if you think that she might have these complications. Based on the info given, you can't really tell. In PP and a BMI of this magnitude + fetal distress = 2 OB/GYN and a quick 45 min. section. The cardiac changes that occur immediately after delivery are significant and your worries are real. So a MVA (.5 vs 2cm2) is helpful in determining need for intubation. Impossible intubation before pre-eclampsia/help syndrome needs critical thinking and r/b stratification in order to prepare a good plan, of which an awake trach is an option.

                                    I'm not that scared of 2 prbc's and 3packs of platelets if the MV and pulm htn are not at least moderate. One of the most common causes of death in the OB population is respiratory and the h/o of impossible intubation is scary. I know you know this. ;)

                                    Good job with your responses. The examiner would see you as a critical thinker and this is what they want to hear. :thumbup:

                                    These are difficult scenarios indeed.
                                     

                                    fakin' the funk

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                                      i thought about this, i also wonder if it would be a better idea to assume the (small?) risk of an epidural hematoma with a single shot spinal over the risk of inducing GA in this patient.

                                      I was actually taken aback by how rare epidural hematoma (in patients with normal coagulation status [1:100000-1000000] is vs. aspiration/difficult DL/difficult BMV in the parturient (~1%). We spend a lot of time worrying about this exceedingly rare complication.
                                       

                                      fakin' the funk

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                                        FWIW I think RSI is a kill error for someone with a known impossible airway even before pregnancy.

                                        True...well said.

                                        In the oral board scenario though, they're going to contraindicate neuraxial, not allow time for an awake FOB, have the surgeon refuse to do local, and if you try to do mask+ketamine+nitrous they'll have the pt aspirate.

                                        So they'll make you put the pt to sleep...right? Mask induction? Spontaneously ventilating IV induction with ketamine or etomidate?
                                         
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