OB Scenario: What would you do?

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pinkMD12

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Clinical scenario:
Called stat to OB, walk in pt's BP 240s/120s, mentating appropriately. Told by OB attending healthy 30yo G1P0 with h/o drug use (not sure what) coming in with elevated BP and headache. Baby not doing well and they want to cut (baby bradycardic, 40s). What would you do?
 
No labs or additional info? Crash c/s? Ask about allergies and personal/familial anesthetic history as we push her back to OR then GETA.
 
Jay K said:
No labs or additional info? Crash c/s? Ask about allergies and personal/familial anesthetic history as we push her back to OR then GETA.
Click to expand...

Crash section yes. The only thing I was told is her platelets were in 50s and "INR high."
 
pinkMD12 said:
Crash section yes. The only thing I was told is her platelets were in 50s and "INR high."
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Also some accreta on top of cocaine use, with DIC? 😀

And/or severe pre-eclampsia, of course.

Edit: Of course I meant abruptio placentae, not accreta. :bang:
 
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Having fun yet, pinkMD12? 🙂

Platelets in the 50s, high INR, adieu neuraxial anesthesia! From what you describe, it's awake FO time, baby! If no time for that, informed consent from mother, who could die there even with the best RSI airway master, if not from hypoxia then from aspiration. Then RSI.

The baby has no rights here, the mother does, hence she needs to know what she needs to know. Let's hope you can talk as fast as the disclaimer guys in the TV ads. Anyway, if the baby is in the 40s, the cut time was 20 minutes ago. Is it a boy? Is it a girl? No, it's a vegetable. 😛

</trolling>
 
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Patient on mag. No time for FOI, patient too anxious for this and now baby's HR is in 20s. While I'm deciding the next step, I tell OB nurses to wheel pt to OR. Where would you go from here? Also keep in mind patient's BP still in 240s/120s.
 
Jay K said:
No labs or additional info? Crash c/s? Ask about allergies and personal/familial anesthetic history as we push her back to OR then GETA.
Click to expand...

BTW, if you can't intubate the patient within seconds, place a Proseal LMA and insert a foley catheter in via the esophageal port, gently inflate that baby and apply suction.
 
Make sure you have all the help you can get including someone who can do a surgical airway if possible, position properly, prepxygenate while placing monitors, Propofol ->Sux --> Glidescope --> tube, if not successful after one attempt immediately place LMA and proceed with surgery.
Don't worry about the KFC in stomach just keep her deep enough so she does not vomit.
Work on BP and other issues later.
 
Jay K said:
BTW, if you can't intubate the patient within seconds, place a Proseal LMA and insert a foley catheter in via the esophageal port, gently inflate that baby and apply suction.
Click to expand...
That sounds like an interesting trick (the Foley).
 
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To the OR. Prop, sux, tube with a glide scope. Have someone present who can do a surgical airway. After intubation, they can cut. Then she gets some big IV's or a neck line. With a BP that high and a baby doing that poorly, there's real chance she's had a big abruption and may have a big bleed after the baby comes out.
 
What's the mother's heart rate?


pinkMD12 said:
Patient on mag. No time for FOI,
Click to expand...

I'm not saying I would do a FOI here, but there's never "no time for FOI" if you think the patient might DIE if you induce her and can't secure that airway. In such a case the bradycardic baby is an incidentaloma. It's not unlikely that the brain-dead hypoxic baby has had a HR of 40 for hours now. No reason to add a second death to the fetal death.


pinkMD12 said:
patient too anxious for this and now baby's HR is in 20s. While I'm deciding the next step, I tell OB nurses to wheel pt to OR. Where would you go from here? Also keep in mind patient's BP still in 240s/120s.
Click to expand...

She needs BP control. This is a hypertensive crisis affecting at least one end organ (uterus). Cocaine and meth are of course on the differential, along with eclampsia. If she's abrupted because of cocaine and/or eclampsia & HTN and has been bleeding for a long time you have your answer for thrombocytopenia and you need to be prepared for a lot more bleeding when the OBs cut. The FHR may be 40 because she's so vasoconstricted that no blood is getting to the uterus. Labetalol and nitroglycerine for starters, while the OBs are yelling baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby baby because no one there is interested in the mother except you.

Then go ahead and bet her life on whatever airway approach you favor. Propofol'll be good for her hypertension too.
 
1) call for stat blood to OR
2) call for more help if available
3) get someone (MD, CRNA, RN) to place additional IV access while you work (after that, a-line)
4) get RNs to prep the patient for incision
5) get OBs in OR scrubbed
6) gentle versed for anxiolysis, careful not to snow her
7) preO2 and nebulized Lidocaine
8) superior laryngeal nerve blocks and transtracheal nerve block
9) attempt awake FOI
10) while intubating, tell OBs they go for a local field block and then start cutting if they feel that strongly about it
11) intubation? --> GETA
12) if you can't get the FOI proceed with field block C/S
13) apply face mask with strap and O2/N2O and you can try giving a little bit of ketamine for analgesia (with esmolol/nitroglycerine boluses or nicardipine for BP control)
14) not tolerating field block? ---> RSI ketamine slug with sux (watch her BP and Rx PRN as above), DL vs Videolaryngoscopy vs whatever you want, then GETA
15) still cant intubate? --> ILMA or LMA on hand, pass OG tube, suck out the Colonel Sanders slushy and give her the volatile to keep her out of stage 2.
16) Cant ventilate? --> surgical airway
17) once baby's out, turn off volatile switch to opiate / N2O technique
 
Jay K said:
BTW, if you can't intubate the patient within seconds, place a Proseal LMA and insert a foley catheter in via the esophageal port, gently inflate that baby and apply suction.
Click to expand...

Wouldn't an OG tube be better? Bigger lumen, multiple ports. The foley catheters are narrow inside and will occlude promptly. Plus, why would you want to obstruct the egress of stomach content by inflating the balloon? You are defeating the purpose of the Proseal LMA.
 
pinkMD12 said:
Clinical scenario:
Called stat to OB, walk in pt's BP 240s/120s, mentating appropriately. Told by OB attending healthy 30yo G1P0 with h/o drug use (not sure what) coming in with elevated BP and headache. Baby not doing well and they want to cut (baby bradycardic, 40s). What would you do?
Click to expand...
How many weeks of gestation? Less than 24 you might not have to do anything.

BP needs to be controlled. I would probably use a mixture of nicardipine and labetalol.

If airway looks extremely challenging she needs an awake fiberoptic. There is always time for that. Bradycardic baby is the lesser priority.

I would probably go with the Glidescope if mouth opens wide. 2 big IV's. I'm on the fence about an a line.

I can imagine the nurses and OB all stressed out and hyper. A total mess usually. I don't miss OB.
 
urge said:
Wouldn't an OG tube be better? Bigger lumen, multiple ports. The foley catheters are narrow inside and will occlude promptly. Plus, why would you want to obstruct the egress of stomach content by inflating the balloon? You are defeating the purpose of the Proseal LMA.
Click to expand...

I would suction her after things calmed down (infant delivered and resuscitated) with a proper OGT. I just didn't want stuff coming UP initially, but admittedly I've never done the former (with a foley); I was given a scenario, and I thought I'd play with it. 😉
 
Planktonmd said:
I am not sure about Ketamine if the BP is 220
Click to expand...

Use labetolol to offset prn. ive used ketamine to limp an iffy epidural thru a c/s before. Catechols are already maxed out; the midaz/ketamine is just as likely to bring BP down a bit than to bring it up.
 
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caligas said:
Surgical aiway is a joke if the pt is crashing from hypoxia. Dont rely on that as a back up.
Click to expand...
Not sure I understand this - when other choices are exhausted, isn't this always your plan Z?
 
Of course do it if it comes to that. Im saying dont count on it as plan B or C for a severly edemetous parturient.
 
This sounds like an oral board scenario. You can do anything you want, just don't induce this patient for your exam because you won't be able to ventilate, oxygenate, trach, or crich this patient. Your spinal will fail and will not work after you try 10 times. You will fail the exam putting this patient to sleep. I belive you just tell OB to start injecting local while you control BP with your miracle drugs. Also start with a basic history and physical exam before starting this adventure. Obviously real life has a different answer.
 
caligas said:
Use labetolol to offset prn. ive used ketamine to limp an iffy epidural thru a c/s before. Catechols are already maxed out; the midaz/ketamine is just as likely to bring BP down a bit than to bring it up.
Click to expand...
Would you give Labetalol to a parturient with a fetal heart rate of 40?
 
Planktonmd said:
Would you give Labetalol to a parturient with a fetal heart rate of 40?
Click to expand...

With a fetal rate of 40 I would do what I could to safely facilitate delivery. In this case that might mean using ketamine. Ketamine might or might not increase BP. For the BP, I might use labetolol depending on MATERNAL heart rate.

Fetal rate is low bc baby is dying, labetolol for mom wont change that.
 
caligas said:
With a fetal rate of 40 I would do what I could to safely facilitate delivery. In this case that might mean using ketamine. Ketamine might or might not increase BP. For the BP, I might use labetolol depending on MATERNAL heart rate.

Fetal rate is low bc baby is dying, labetolol for mom wont change that.
Click to expand...
If the baby does not matter then this case is not an emergency and you have plenty of time!
 
Planktonmd said:
If the baby does not matter then this case is not an emergency and you have plenty of time!
Click to expand...
You lost me there. Never said baby does not matter.

I think the key message for the young folks is the following:

our goals with a "bad baby" stat c/s are
1) rapid delivery
2) safe mom
3) no pain

with the op's scenario (bad baby/bad airway) you can really only assure 2 of those 3. You pick which two. Want 1 and 3? Do an RSI. Want 2 and 3? Awake fiberoptic. 1 and 2? Ketamine/local.
 
if fetus viable

call for help / blood
consent - including death and awareness
to OR
IV
pre oxygenate
14g canula through cricothyroid membrane pre induction
optimal position
generous opioid - want BP stable with laryngoscopy (alfentanil ideally), propofol, sux 2mg/kg with cricoid pressure
-- OB can cut

plan a - laryngoscope of choice - tube
plan b - VLS +/- bougie, tube
plan c - LMA classic - ventilate - cricoid pressure if it doesn't impede ventilation, oxygenate -- FO & ETT through LMA
plan d - bag & mask with cricoid, baby out, LA, wake up
plan e - oxygenate via canula, baby out, LA, wake up
plan f - scalpel (puncture), bougie, tube (an ENT surgeon would be nice but I assume it's 4am and raining outside)
plan g - scalpel - vertical incision, finger, tube
plan h - look for a new job

this thread is a cliche - but an important one
 
Where are the retrograde wire and ECMO options? 😛
 
FFP said:
I was actually wondering earlier if anybody has ever done this in real life.
Click to expand...
I have. In residency. A drug addict came in and the baby's heart rate was either low or they couldn't find it and she was bleeding. IV had been placed by paramedics, but on transfer to the OR bed in the mayhem,it was lost. My attending tried to get a CVC while I tried to get a peripheral in an IVDA. No dice. OB is panicking, and patient is out of her mind on drugs and people coming at her in all directions. I put a mask on her face, turned on some gas,told my attending we needed to proceed with local while he was still struggling for aline, he agreed. I told the OB to use lidocaine and all the staff in the OR to hold down the patient. They cut, she screamed and tried to come off the table but was held down but staff. We masked the patient and after baby was out, I was able to get a 22gauge on her thumb, then tubed her, and suctioned her before we extubated. She didn't remember much thank God, because she was already out of her mind on drugs.

Thank God she didn't aspirate, but she was also a skinny little thing. I think the baby lived long enough to go to NICU, not sure after that, because he/she was premature and addicted.

Did an M&M and researched Mendelson's syndrome, which is very, very rare, BTW, but in this country of litigation , we are always planning for it.
 
Planktonmd said:
Is it really OK to give beta blockers the mother in the presence of severe fetal bradycardia???
Click to expand...
My "sure" probably deserved a longer reply, so -

Sure. Most fetal decels are autonomic reflexes, which could conceivably be made worse by giving a beta blocker to the mother, but this fetus (at a hr of 40) is bradycardic because of hypoxia and the mother is in the midst of a hypertensive crisis. The fetus won't recover without either improved uterine blood flow or delivery. Fixing the mother's hypertension may improve uterine blood flow; it's also a prerequisite for any stimulating procedure like a hasty awake airway intervention for GA or a c-section under local, unless you want mom to have a stroke.

So yes I would be OK using labetalol in this patient. NTG would be my first choice for speed and potency, but in this patient my r/b analysis is ok with labetalol.
 
Ezekiel2517 said:
Not in this same scenario, but I've seen it done by colleagues. Worked like a charm
Click to expand...


It's called a TIVA and it works fine. The local part is B.S. as you are giving enough drugs for a TIVA based GA. FYI, low dose ketamine doesn't increase BP or HR provided you keep the bolus doses under 50 mg.

For me this case is a Glidescope from the start followed by a Proseal LMA if the Glidescope fails. Arterial line placement at some point during the case with good IV access for Vasoactive drugs if needed (those could be anything from Noreip to Nitroprusside).
 
Can J Anaesth. 2012 Jul;59(7):648-54. doi: 10.1007/s12630-012-9718-4. Epub 2012 May 4.
The LMA Supreme™ in 700 parturients undergoing Cesarean delivery: an observational study.
Yao WY1, Li SY, Sng BL, Lim Y, Sia AT.
Author information

Abstract
BACKGROUND:
The LMA Supreme™ (SLMA) is a single-use supraglottic device that provides a good seal for positive pressure ventilation. It has a double aperture design that facilitates the introduction of an orogastric tube to aspirate gastric contents. This observational study evaluated the role of the SLMA in parturients undergoing Cesarean delivery under general anesthesia.

METHODS:
Non-obese parturients with at least four hours of fasting and antacid prophylaxis scheduled for uncomplicated Cesarean delivery were recruited from June 2009 through May 2010 at the Quanzhou Women's and Children's Hospital, China. We recorded the number of SLMA insertion attempts, the time to effective ventilation, the incidence of aspiration, and other anesthetic and obstetric outcomes. Postoperatively, we noted the presence of blood on the SLMA, postoperative sore throat, and patient satisfaction. Analysis included comparison of results between parturients having elective and urgent Cesarean delivery.

RESULTS:
We recruited 700 parturients (576 elective, 124 urgent). Mean (standard deviation) body mass index was 25.6 (2.5) kg·m(-2). All SLMA insertions were successful, with 686 (98%) inserted on first attempt and a time to effective airway of 19.5 (3.9) sec. We maintained ventilation and oxygenation in all parturients with a good seal and there was no evidence of aspiration. Eighteen parturients (2.6%) had blood on the SLMA upon removal, 24 (3.4%) had sore throat, and patient satisfaction was 85 (7)%. These results were similar in elective and urgent cases.

CONCLUSIONS:
In a carefully selected group of parturients, the SLMA is a useful alternative to tracheal intubation for Cesarean delivery, providing effective ventilation and a low incidence of side effects or complications.
 
Anaesth Intensive Care. 2010 Nov;38(6):1023-8.
The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases.
Halaseh BK1, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H.
Author information

Abstract
Rapid sequence induction is currently the recommended technique in general anaesthesia for caesarean section. However, the usefulness of the ProSeal laryngeal mask airway as a rescue airway in the event of difficult or failed intubation has been recognised in numerous case reports. In this study, we report the experience of the use of the ProSeal laryngeal mask in 3000 elective caesarean sections in a single centre, using a method of insertion that allows a rapid establishment of a patent airway together with gastric drainage.
 
Can J Anaesth. 2001 Dec;48(11):1117-21.
The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective Cesarean section: a prospective study of 1067 cases.
Han TH1, Brimacombe J, Lee EJ, Yang HS.
Author information

Abstract
PURPOSE:
To report on the use of the laryngeal mask airway (LMA) for elective Cesarean section in 1067 consecutive ASA I-II patients preferring general anesthesia.

METHODS:
Patients were excluded if they had pharyngeal reflux, a pre-pregnancy body mass index >30, or had a known/predicted difficult airway. Patients were fasted for six hours and given ranitidine/sodium citrate. A rapid sequence induction was performed with thiopentone and suxamethonium. The LMA was inserted by experienced users. Anesthesia was maintained with N(2)O and 50% O(2) and a volatile agent. Cricoid pressure was maintained until delivery, but was relaxed if insertion/ventilation was difficult. Patients were intubated if an effective airway was not obtained within 90 sec, or SpO(2) <94%, or end-tidal CO(2) >45 mmHg. Postdelivery, vecuronium and fentanyl were administered.

RESULTS:
An effective airway was obtained in 1060 (99%) patients, 1051 (98%) at the first attempt and nine (1%) at the second or third attempt. Air leakage or partial airway obstruction occurred in 22 (21%) patients, and seven (0.7%) patients required intubation. There were no episodes of hypoxia (SpO(2) <90%), aspiration, regurgitation, laryngospasm, bronchospasm or gastric insufflation. Surgical conditions were satisfactory and all APGAR scores were >/=7 after five minutes.

CONCLUSION:
We conclude that the LMA is effective and probably safe for elective Cesarean section in healthy, selected patients when managed by experienced LMA users.
 
BLADEMDA said:
Anaesth Intensive Care. 2010 Nov;38(6):1023-8.
The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases.
Halaseh BK1, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H.
Author information

Abstract
Rapid sequence induction is currently the recommended technique in general anaesthesia for caesarean section. However, the usefulness of the ProSeal laryngeal mask airway as a rescue airway in the event of difficult or failed intubation has been recognised in numerous case reports. In this study, we report the experience of the use of the ProSeal laryngeal mask in 3000 elective caesarean sections in a single centre, using a method of insertion that allows a rapid establishment of a patent airway together with gastric drainage.
Click to expand...
Keyword: elective.
Patients were excluded if they had pharyngeal reflux, a pre-pregnancy body mass index >30, or had a known/predicted difficult airway.
Click to expand...
Really useful study.😆
 
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FFP said:
Keyword: elective.

Really useful study.😆
Click to expand...


The CHIEF of OB Anesthesia used that same study in his presentation (see video above). He recommends the use of Proseal LMAs for difficult to intubate cases in OB.

Richard Smiley, M.D. Ph.D.
Chief of OB Anesthesia
Columbia University
 
I completely agree with him. I use LMAs for everything I can in my outpatients, except for stuff that would be unpleasant to defend in court. And they are definitely my escape airways if I can't intubate (and/or ventilate).

I just found it laughable that somebody did a "study" to prove that LMAs are safe to be used in elective C-sections on healthy thin gravidas not in labor. Seriously? Like we don't already know that the main risk of aspiration is during labor, not the third trimester.

Even more laughable is protecting against aspiration with Sellick's maneuver, while the LMA is in place. If one is afraid of aspiration, one should not put in an LMA in a thousand patients, period; that maneuver has been proved semi-useless time after time.
Cricoid pressure was maintained until delivery, but was relaxed if insertion/ventilation was difficult.
Click to expand...
 
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