OB case

[chessknt]

Saw this last week, curious how y'all would have approached.

26F h/o meth and etoh abuse showed up to maternity clinic at 36w pregnant with dyspnea no prenatal care prior. Had TTE done in clinic showing EF 30% and was instructed to admit for further workup but declined. A week later showed up by EMS with hemoptysis, given therapeutic lovenox in ER (no idea why), CTA showed pulmonary edema, admitted to ICU for SROM and active labor 4cm dilated station 0, contractions every 3-4 minutes.

Breathing 30-40 times per minute, put on bipap with no significant change in RR MV read as low 30s. ABG (on bipap 12/8) 7.35/27/200, labs notable for bicarb 17 and albumin 1 for adjusted gap of 15. UDS + meth. EKG shows sinus tachy low 100s, satting fine on 30% FIO2. SBP 110-130. Troponin normal, BNP high. Meets preeclampsia criteria. Lactate normal, etoh neg. Ob worried about being unable to control pain with therapeutic lovenox and asking for C section. Pt mental status not great, when not having a contraction she is somnolent and arouses only to noxious stimuli but has excellent respiratory drive and protecting airway. Got 25 mcg fentanyl x1 an hour ago.

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[Mman]

Saw this last week, curious how y'all would have approached.

26F h/o meth and etoh abuse showed up to maternity clinic at 36w pregnant with dyspnea no prenatal care prior. Had TTE done in clinic showing EF 30% and was instructed to admit for further workup but declined. A week later showed up by EMS with hemoptysis, given therapeutic lovenox in ER (no idea why), CTA showed pulmonary edema, admitted to ICU for SROM and active labor 4cm dilated station 0, contractions every 3-4 minutes.

Breathing 30-40 times per minute, put on bipap with no significant change in RR MV read as low 30s. ABG (on bipap 12/8) 7.35/27/200, labs notable for bicarb 17 and albumin 1 for adjusted gap of 15. UDS + meth. EKG shows sinus tachy low 100s, satting fine on 30% FIO2. SBP 110-130. Troponin normal, BNP high. Meets preeclampsia criteria. Lactate normal, etoh neg. Ob worried about being unable to control pain with therapeutic lovenox and asking for C section. Pt mental status not great, when not having a contraction she is somnolent and arouses only to noxious stimuli but has excellent respiratory drive and protecting airway. Got 25 mcg fentanyl x1 an hour ago.

Prop/sux/tube (except I would probably use something like ketamine/etomidate instead of prop), art line, ICU overnight to see how her heart adjusts to fluid shifts postop.

 

[UnbentLaryngoscope]

Ob worried about being unable to control pain with therapeutic lovenox and asking for C section.

So, the OB is worried about inadequate pain control here? And the proposed solution is a c-section? Last time I checked pain isn't an indication for cesarean delivery.

Is the OB not concerned about performing a c-section on a patient that received a therapeutic dose of lovenox? Under GA because neuraxial is contraindicated no less. Remind the obstetrician that lovenox can only be partially reversed with protamine, and that volatile anesthetics are associated with decreased uterine tone. We could very easily find ourselves up to our ankles in blood with this case. In a patient with amphetamine associated cardiomyopathy. Not good.

Or we can let the patient have pain, and deliver vaginally. That's my recommendation, provided there aren't any actual maternal or fetal indications for cesarean delivery.

 

[vector2]

Let's see....she's a methhead, she's gotten therapeutic lovenox, has hemoptysis and pulmonary edema, BNP is elevated, is breathing 35 times a minute on bipap, and is somnolent somewhere on the spectrum of deep sedation to general anesthesia before she's even received anything


I think you need your head examined if you'd do anything other than GETA, a-line, section, and return to ICU intubated.

 

[Arch Guillotti]

Let's see....she's a methhead, she's gotten therapeutic lovenox, has hemoptysis and pulmonary edema, BNP is elevated, is breathing 35 times a minute on bipap, and is somnolent somewhere on the spectrum of deep sedation to general anesthesia before she's even received anything


I think you need your head examined if you'd do anything other than GETA, a-line, section, and return to ICU intubated.

Exactly. This patient is a disaster waiting to happen and the case needs to be done with the utmost of caution.

 

[GassYous]

I'm not doing this section.

 

[Arch Guillotti]

I'm not doing this section.

Hell no. Dump it on an unsuspecting partner.

 

[dhb]

Let's not forget to follow the protocol here:

A Airway: ok
B Balls: the balls of the person who gave a therapeutic dose of lovenox need to be kicked in before proceeding to
C C-section

 

[dannyboy1]

Simple. Tube, keep her alive for the hour long CS and send her to the ICU intubated where cards can optimize/fix her.

 

[abolt18]

Any major guesses as to the right of her AGMA?

If c-section happens, GA for sure. Obviously continue to hyperventilate under GA in an attempt to normalize pH until you can identify and treat the cause of her metabolic acidosis.

But as noted above, why can this lady not just deliver vaginally without an epidural?

 

[deleted697127]

Saw this last week, curious how y'all would have approached.

26F h/o meth and etoh abuse showed up to maternity clinic at 36w pregnant with dyspnea no prenatal care prior. Had TTE done in clinic showing EF 30% and was instructed to admit for further workup but declined. A week later showed up by EMS with hemoptysis, given therapeutic lovenox in ER (no idea why), CTA showed pulmonary edema, admitted to ICU for SROM and active labor 4cm dilated station 0, contractions every 3-4 minutes.

Breathing 30-40 times per minute, put on bipap with no significant change in RR MV read as low 30s. ABG (on bipap 12/8) 7.35/27/200, labs notable for bicarb 17 and albumin 1 for adjusted gap of 15. UDS + meth. EKG shows sinus tachy low 100s, satting fine on 30% FIO2. SBP 110-130. Troponin normal, BNP high. Meets preeclampsia criteria. Lactate normal, etoh neg. Ob worried about being unable to control pain with therapeutic lovenox and asking for C section. Pt mental status not great, when not having a contraction she is somnolent and arouses only to noxious stimuli but has excellent respiratory drive and protecting airway. Got 25 mcg fentanyl x1 an hour ago.

Honestly not impressed with any of this. That ABG looks great. Patients that are withdrawing from meth look sedated. Meth isn’t an opiate so I’m not sure why anyone’s worked up about pain control. Like what someones sternal rubbing her and asking her what her pain scores are to titrate fentanyl? Do patients at 4cm usually need opiates? No, they don’t. People have vaginal delivery and ex laps without neuraxial all the time.

But why does any of this need intervention right now? Just just give some lasix and let her sleep. Or if they want to do the c section just tube her.

 

[chessknt]

Great variety of answers. I think there was significant debate over whether or not to try to deliver vaginally or in OR but decision was ultimately made to go to OR

Let’s assume that delivery by c section is the best option in her scenario. She is in active labor and has had almost no optimization due to the presentation and time course thus far with clear volume overload and doesn’t have time to be optimized further.

What is your induction plan? Anything special/proactive when baby comes out and all that uterine boood volume starts to get returned to her globally akinetic heart?

 

[deleted126335]

Great ? Anything special/proactive when baby comes out and all that uterine boood volume starts to get returned to her globally akinetic heart?

Phlebotomy from the surgical field from Lovenox/Inhalational agent.

 

[GassYous]

Great variety of answers. I think there was significant debate over whether or not to try to deliver vaginally or in OR but decision was ultimately made to go to OR

Let’s assume that delivery by c section is the best option in her scenario. She is in active labor and has had almost no optimization due to the presentation and time course thus far with clear volume overload and doesn’t have time to be optimized further.

What is your induction plan? Anything special/proactive when baby comes out and all that uterine boood volume starts to get returned to her globally akinetic heart?

They are gonna take forever and lose at least 2 L despite pit, hemabate, cytotec etc. You need large bore access for resuscitation, not fluid overload.

 

[coffeebythelake]

and that volatile anesthetics are associated with decreased uterine tone. We could very easily find ourselves up to our ankles in blood with this case.

You don't need to use volatile agent.. just saying.

 

[coffeebythelake]

What is your induction plan? Anything special/proactive when baby comes out and all that uterine boood volume starts to get returned to her globally akinetic heart?

Lasix and epi gtt

 

[UnbentLaryngoscope]

Give protamine to reverse as much of the lovenox as you can. Pre-induction art line. Large bore PIV if she has good peripheral targets. If she injects meth she may not have appropriate targets, in which case 9 Fr MAC catheter. Have the blood bank send 4 reds to the room. Bring all of the uterotonics to the room. The obstetrician will "correct" the volume overload for us.

Then etomidate/sux/tube. Norepi rather than phenylephrine or ephedrine for vasopressor support in this case. Maintenance with volatile in 70% N2O. Give 1 gram TXA. Transfuse PRN. Give uterotonics PRN (probably all of them). Encourage the OB to just do a hysterectomy sooner rather than later. Intubated to ICU postop.

The point about volatile anesthetic not being necessary is valid, you certainly could do a TIVA here, or a mixed N2O/propofol anesthetic to avoid smooth muscle relaxation from volatile agents. But c-section under GA is a risk factor for intraoperative awareness. So is TIVA. Too many other things to worry about here other than fiddling with TIVA drips. I'll just use N2O and some fentanyl to minimize the volatile requirement as much as possible.

 

[Lidolover]

Omg! one more example of how surreal obstetric ppl can be.
I think the priority here is to put this patient in a different spot in the Frank - Starling curve. As already mentioned, she needs diuresis without delay and delay as much as possible her delivery as long as the fetal tracing is not concerning. She won’t be able to tolerate that fluid overload that happens postpartum.
Also, pay attention to her valves. Even mild AR or MR can be detrimental post partum.

even if she had therapeutic lovenox, she still qualifies for neuraxial 24 hrs later ...

 

[deleted697535]

Mild AR or MR can be detrimental? Can you post something about that?

OB worried about poor pain control means what to us exactly?
Am i missing something here?

 

[chessknt]

Doesn’t inject meth vascular access is good.

Mild mr on tte other valves fine

Ob says fetal distress present and given stage of labor don’t have much time on the order of hours and that big volume shift could kill baby.

Concern from cards about distress with worsening tachycardia (went from low 100s to 120s sinus in past hour of labor) from uncontrolled pain worsening cardiac function.

Delivery in or decided in order to have access to mechanical support and surgical resources if things go south.

Icu does a rotem that shows normal clotting function despite dose of therapeutic lovenox 4 hours ago.

Ill update what happened Intraop and postop tomorrow.

 

[deleted697127]

Give protamine to reverse as much of the lovenox as you can. Pre-induction art line. Large bore PIV if she has good peripheral targets. If she injects meth she may not have appropriate targets, in which case 9 Fr MAC catheter. Have the blood bank send 4 reds to the room. Bring all of the uterotonics to the room. The obstetrician will "correct" the volume overload for us.

Then etomidate/sux/tube. Norepi rather than phenylephrine or ephedrine for vasopressor support in this case. Maintenance with volatile in 70% N2O. Give 1 gram TXA. Transfuse PRN. Give uterotonics PRN (probably all of them). Encourage the OB to just do a hysterectomy sooner rather than later. Intubated to ICU postop.

The point about volatile anesthetic not being necessary is valid, you certainly could do a TIVA here, or a mixed N2O/propofol anesthetic to avoid smooth muscle relaxation from volatile agents. But c-section under GA is a risk factor for intraoperative awareness. So is TIVA. Too many other things to worry about here other than fiddling with TIVA drips. I'll just use N2O and some fentanyl to minimize the volatile requirement as much as possible.

I know it’s possible but I don’t get the impression that many people shoot up meth. But then again maybe it’s just regional bias and where I’m at the druggies are more conscientious of their use of plastic products.

Sounds like she’s already hovering at .6 Mac. I would be less concerned about her risk of awareness than an amped up otherwise healthy 23 year old crash section.

Agree with epi or vaso as choice of pressor. Doesn’t much matter but low threshold to upgrade to something that increases contractility if phenylephrine isn’t responding appropriately. She’s the definition of catecholamine depleted.

Define the concern and justification for c section before you jump headfirst into a bad situation. Waiting for lovenox to wear off could make things better, especially if surgeons are slow for normal cases. She’ll probably become more alert as labor progresses.

Im curious what her gas would look like without BIPAP. I have seen altered mental status, BIPAP/CPAP, full stomach, and presumably BIPAP partially inflating the stomach turn out poorly...

 

[deleted697535]

Doesn’t inject meth vascular access is good.

Mild mr on tte other valves fine

Ob says fetal distress present and given stage of labor don’t have much time on the order of hours and that big volume shift could kill baby.

Concern from cards about distress with worsening tachycardia (went from low 100s to 120s sinus in past hour of labor) from uncontrolled pain worsening cardiac function.

Delivery in or decided in order to have access to mechanical support and surgical resources if things go south.

Icu does a rotem that shows normal clotting function despite dose of therapeutic lovenox 4 hours ago.

Ill update what happened Intraop and postop tomorrow.

Ok rotem being used to evaluate lovenox clinical effect is not recommended last i checked. Do you have any data on that?

Ob worried about fluid shifts killing the baby? I assume the fluid shift implied is the auto transfusion on clamping the placenta which is after the baby has been delivered so i dont really understand that...

Cards worried about tachycardia and pain in a sleeping woman? Is that for real? well have they been in many ga section with a recent whopper dose on lovenox... Let me tell you the tachycardia has only just begun. Lets see how her heart deals with a 3 litre transfusion... Sure a c section is a benign intervention

Who is captain of this ship here? Am i missing something? There are a lot of questions...

 

[chessknt]

Ok rotem being used to evaluate lovenox clinical effect is not recommended last i checked. Do you have any data on that?

Ob worried about fluid shifts killing the baby? I assume the fluid shift implied is the auto transfusion on clamping the placenta which is after the baby has been delivered so i dont really understand that...

Cards worried about tachycardia and pain in a sleeping woman? Is that for real? well have they been in many ga section with a recent whopper dose on lovenox... Let me tell you the tachycardia has only just begun. Lets see how her heart deals with a 3 litre transfusion... Sure a c section is a benign intervention

Who is captain of this ship here? Am i missing something? There are a lot of questions...

Effects of unfractionated heparin, low-molecular-weight heparin, and heparinoid on thromboelastographic assay of blood coagulation - PubMed there are others as well. TEG is really a measurement of the physical manifestation of the clotting cascade and logically should be abnormal in setting of any coagulopathy, iatrogenic or otherwise. If it is normal I don't think you can make a compelling argument that you are at high risk for bleeding due to coagulopathy but would defer that to cardiac anesthesiology who have seen far more of it than I have.

Ob was worried about fluid shift of aggressive diuresis to optimize patient killing baby.

Maybe I am not describing it right but with each contraction she was screaming like the devil was in her and her writhing in bed trying to climb out of it and HR would jump an additional 20 points for the duration and as it subsided she would collapse back on to the bed but still be arousable to phsyical stimulus. This was happening q5-7 minutes. She wasnt sleeping through contractions.

Ob is primary but has involved multiple teams in care.

 

[GassYous]

OB and cards sound very tardy. I'd quit listening to anything they say. Worried about awareness? Fetal well being in a meth abuser? Tachycardia in a pregnant woman? All pregnant women are tachycardic. These guys are clueless about physiology. If she has pain give her pain meds. This section is straight up stupid.

 

[deleted875186]

Really weird case. I too am interested in this ABG and here mental status, why is she altered? Is she having seizures or is this overdose or withdrawal?

i think the degree of her preeclampsia and fluid overload need to be gauged and weighed against the risk of waiting for lovenox to wear off. I don’t think the tachycardia is a reason to go ahead with a section. No idea how “fluid shift” will harm the baby, sounds like hand waiving. I’m leaning towards waiting, but clearly the OB thinks this is urgent and is pushing for a section. Clearly the ED doctor thinks he’s all that if he gave therapeutic lovenox.

also, is this a G1, we could be talking many hours of labor at 4 cm?

 

[deleted875186]

Effects of unfractionated heparin, low-molecular-weight heparin, and heparinoid on thromboelastographic assay of blood coagulation - PubMed there are others as well. TEG is really a measurement of the physical manifestation of the clotting cascade and logically should be abnormal in setting of any coagulopathy, iatrogenic or otherwise. If it is normal I don't think you can make a compelling argument that you are at high risk for bleeding due to coagulopathy but would defer that to cardiac anesthesiology who have seen far more of it than I have.

Ob was worried about fluid shift of aggressive diuresis to optimize patient killing baby.

Maybe I am not describing it right but with each contraction she was screaming like the devil was in her and her writhing in bed trying to climb out of it and HR would jump an additional 20 points for the duration and as it subsided she would collapse back on to the bed but still be arousable to phsyical stimulus. This was happening q5-7 minutes. She wasnt sleeping through contractions.

Ob is primary but has involved multiple teams in care.

If this is the case than it’s all drugs, lady is fine, they are sectioning her due to screaming and overall unpleasantness, I would tell them to give pain meds, wait 24 hours and do an epidural.

 

[deleted697127]

Effects of unfractionated heparin, low-molecular-weight heparin, and heparinoid on thromboelastographic assay of blood coagulation - PubMed there are others as well. TEG is really a measurement of the physical manifestation of the clotting cascade and logically should be abnormal in setting of any coagulopathy, iatrogenic or otherwise. If it is normal I don't think you can make a compelling argument that you are at high risk for bleeding due to coagulopathy but would defer that to cardiac anesthesiology who have seen far more of it than I have.

Ob was worried about fluid shift of aggressive diuresis to optimize patient killing baby.

Maybe I am not describing it right but with each contraction she was screaming like the devil was in her and her writhing in bed trying to climb out of it and HR would jump an additional 20 points for the duration and as it subsided she would collapse back on to the bed but still be arousable to phsyical stimulus. This was happening q5-7 minutes. She wasnt sleeping through contractions.

Ob is primary but has involved multiple teams in care.

I assure you that you have a better grasp on volume status than the OBs do. What’s so scary about diuresis? Insert a Foley. Diurese. See what happens. You can always give fluids back.

 

[GassYous]

Effects of unfractionated heparin, low-molecular-weight heparin, and heparinoid on thromboelastographic assay of blood coagulation - PubMed there are others as well. TEG is really a measurement of the physical manifestation of the clotting cascade and logically should be abnormal in setting of any coagulopathy, iatrogenic or otherwise. If it is normal I don't think you can make a compelling argument that you are at high risk for bleeding due to coagulopathy but would defer that to cardiac anesthesiology who have seen far more of it than I have.

Ob was worried about fluid shift of aggressive diuresis to optimize patient killing baby.

Maybe I am not describing it right but with each contraction she was screaming like the devil was in her and her writhing in bed trying to climb out of it and HR would jump an additional 20 points for the duration and as it subsided she would collapse back on to the bed but still be arousable to phsyical stimulus. This was happening q5-7 minutes. She wasnt sleeping through contractions.

Ob is primary but has involved multiple teams in care.

Who cares? Craziness and drug abuse is not an indication for surgery.

 

[fakin' the funk]

Saw this last week, curious how y'all would have approached.

26F h/o meth and etoh abuse showed up to maternity clinic at 36w pregnant with dyspnea no prenatal care prior. Had TTE done in clinic showing EF 30% and was instructed to admit for further workup but declined. A week later showed up by EMS with hemoptysis, given therapeutic lovenox in ER (no idea why), CTA showed pulmonary edema, admitted to ICU for SROM and active labor 4cm dilated station 0, contractions every 3-4 minutes.

Breathing 30-40 times per minute, put on bipap with no significant change in RR MV read as low 30s. ABG (on bipap 12/8) 7.35/27/200, labs notable for bicarb 17 and albumin 1 for adjusted gap of 15. UDS + meth. EKG shows sinus tachy low 100s, satting fine on 30% FIO2. SBP 110-130. Troponin normal, BNP high. Meets preeclampsia criteria. Lactate normal, etoh neg. Ob worried about being unable to control pain with therapeutic lovenox and asking for C section. Pt mental status not great, when not having a contraction she is somnolent and arouses only to noxious stimuli but has excellent respiratory drive and protecting airway. Got 25 mcg fentanyl x1 an hour ago.

Your patient's in shock and the oxygen demand from the fetus ain't helping. CS is indicated for mom and obviously beneficial for fetus. Case will be straightforward, pack mom up intubated to ICU postop. Easy peasy

 

[woopedazz]

Personally, I'd do the following:

1. Attempt to terminate the labour to buy time to optimise.
- Success: Elective cesarean in the coming day(s).
- Failure: Proceed to step 2.
2. Do the cesarean anyway; lines, TIVA, etc.
- I don't want this person in active labour and pushing if they're so shocked they're barely rousable in the latent phase. Do you want this to go down in a semi-controlled environment with lines in place and staff available, or, in the delivery suite a few hours later mid-code?
Every complaint people have for taking the patient emergently to the OR is gonna be worse/more difficult to control in the labour room. They're probably going to decompensate further the longer you wait, unless you can actually halt the progression into the active phase.

 

[deleted697535]

Hold on now a second?
Im only an auld farmer from europe but shocked patient??
Where are people getting this from?


ABG (on bipap 12/8) 7.35/27/200, labs notable for bicarb 17 and albumin 1 for adjusted gap of 15. UDS + meth. EKG shows sinus tachy low 100s, satting fine on 30% FIO2. SBP 110-130. Troponin normal, BNP high. lactate normal

What is the normal bicarb in a term parturient please?

Oxygen demand? Her Po2 is 200 on 30%... Am i missing something here?

Sure her pH is lower than expected given 3rd trim mum are usually resp alkalotic but the bipap clouds this ABG and makes it difficult to interpret but its not vastly outside of what you might expect to be rushing off doing heavy duty stuff 4 hours after therapeutic lovenox (im not sure the normal TEG helps - it can be misleading - there may be cardiac anesthesiolgists on this forum, on this thread even).

 

[coffeebythelake]

I would want to call the ER and figure out why some ***** decided to give this patient therapeutic lovenox for no clear reason. Even if they thought this patient had a PE and didn't want to do a scan to confirm given pregnancy, some thinking ahead should have taken place before giving it (e.g., discuss this with OB and anesthesiologist)

 

[dannyboy1]

Omg! one more example of how surreal obstetric ppl can be.
I think the priority here is to put this patient in a different spot in the Frank - Starling curve. As already mentioned, she needs diuresis without delay and delay as much as possible her delivery as long as the fetal tracing is not concerning. She won’t be able to tolerate that fluid overload that happens postpartum.
Also, pay attention to her valves. Even mild AR or MR can be detrimental post partum.

She will tolerate the fluid shifts well. Due to the presence of the ETT. tube her, section her, send her to ICU. she will be out within a week injecting meth again....

 

[PainDrain]

Saw this last week, curious how y'all would have approached.

26F h/o meth and etoh abuse showed up to maternity clinic at 36w pregnant with dyspnea no prenatal care prior. Had TTE done in clinic showing EF 30% and was instructed to admit for further workup but declined. A week later showed up by EMS with hemoptysis, given therapeutic lovenox in ER (no idea why), CTA showed pulmonary edema, admitted to ICU for SROM and active labor 4cm dilated station 0, contractions every 3-4 minutes.

Breathing 30-40 times per minute, put on bipap with no significant change in RR MV read as low 30s. ABG (on bipap 12/8) 7.35/27/200, labs notable for bicarb 17 and albumin 1 for adjusted gap of 15. UDS + meth. EKG shows sinus tachy low 100s, satting fine on 30% FIO2. SBP 110-130. Troponin normal, BNP high. Meets preeclampsia criteria. Lactate normal, etoh neg. Ob worried about being unable to control pain with therapeutic lovenox and asking for C section. Pt mental status not great, when not having a contraction she is somnolent and arouses only to noxious stimuli but has excellent respiratory drive and protecting airway. Got 25 mcg fentanyl x1 an hour ago.

I’m a little late to this but I’ll post my thoughts. First off, an IVDU who shows up with a depressed EF and hemoptysis? This screams endocarditis. Endocarditis can present with hemoptysis if there is right sided endocarditis or is there is acute wide open MR. Also a depressed EF in a pregnant patient needs to be evaluated for peripartum cardiomyopathy and this can get progress rapidly. She needs to be delivered ASAP and the safest method for all parties is an arterial line, followed by GA.

 

[Mman]

I’m a little late to this but I’ll post my thoughts. First off, an IVDU who shows up with a depressed EF and hemoptysis? This screams endocarditis. Endocarditis can present with hemoptysis if there is right sided endocarditis or is there is acute wide open MR. Also a depressed EF in a pregnant patient needs to be evaluated for peripartum cardiomyopathy and this can get progress rapidly. She needs to be delivered ASAP and the safest method for all parties is an arterial line, followed by GA.

here's a related but separate thought....if the OB says the patient needs a c-section to get the baby out, I don't really get a say in it. I mean from a medico-legal point of view just sign the check if you refuse and there is a bad outcome. I mean there is already probably going to be a bad outcome of some sort, don't put the bullseye on yourself.

 

[Lidolover]

Sure guys all these options are valid.
they used to do a cholecystectomy and pts had to be hospitalized for a week and some of them in the ICU. We have progressed a bit since then. Now it’s a day surgery (almost lol) in some centers. Same with this patient. Our goal is not only how to escape death for this (or any patient) but how to provide the best possible care with the least complications and suffering/pain. This is the beauty of our specialty to me...and the difference various providers can make in such situations. Sometimes tube sux icu is the easiest and at times safest option but I still believe we have many tools nowadays to do better than that.

 

[vector2]

Sure guys all these options are valid.
they used to do a cholecystectomy and pts had to be hospitalized for a week and some of them in the ICU. We have progressed a bit since then. Now it’s a day surgery (almost lol) in some centers. Same with this patient. Our goal is not only how to escape death for this (or any patient) but how to provide the best possible care with the least complications and suffering/pain. This is the beauty of our specialty to me...and the difference various providers can make in such situations. Sometimes tube sux icu is the easiest and at times safest option but I still believe we have many tools nowadays to do better than that.

I don't think anyone here is saying geta, a-line, ICU merely out of convenience.

In my opinion it is the safest and best course for this pt given her presentation, full stop.

 

[Mman]

Sometimes tube sux icu is the easiest and at times safest option but I still believe we have many tools nowadays to do better than that.

Sure we can often times do something different, just not this patient. They are getting a GA. There is not any other good (or better) option. And they were in the ICU preop and deserve to be in the ICU postop.

The better now is you can go crazy and do some echo or use fancy toys to guide your fluid management. But they are still getting a tube.

 

[deleted875186]

Your patient's in shock and the oxygen demand from the fetus ain't helping. CS is indicated for mom and obviously beneficial for fetus. Case will be straightforward, pack mom up intubated to ICU postop. Easy peasy

Maybe this is shock, but there’s no info here to diagnose it, what evidence of organ hypoperfusion is there? There’s altered mental status, but maybe this is just intoxication or withdrawal?

ABG is not bad. There is pulmonary edema, but no hypoxia.

Before we assume this cardiomyopathy is peripartum cardiomyopathy or some result of preeclampsia, an IVDU and chronic meth user with no health care prior to pregnancy has plenty of reasons to have cardiomyopathy. Hard to tell with seeing her or having more info if she’s in decompressed heart failure, I think many of the posts above saying go straight to section are assuming this.

 

[PainDrain]

Maybe this is shock, but there’s no info here to diagnose it, what evidence of organ hypoperfusion is there? There’s altered mental status, but maybe this is just intoxication or withdrawal?

ABG is not bad. There is pulmonary edema, but no hypoxia.

Before we assume this cardiomyopathy is peripartum cardiomyopathy or some result of preeclampsia, an IVDU and chronic meth user with no health care prior to pregnancy has plenty of reasons to have cardiomyopathy. Hard to tell with seeing her or having more info if she’s in decompressed heart failure, I think many of the posts above saying go straight to section are assuming this.

As stated above, If the baby isn’t looking great and the OB says they want to head to section then you have literally 30 minutes to cut. If you throw a fit and tell the OB to hold on and there is a bad outcome, like Mman said “write the check.”

 

[deleted875186]

As stated above, If the baby isn’t looking great and the OB says they want to head to section then you have literally 30 minutes to cut. If you throw a fit and tell the OB to hold on and there is a bad outcome, like Mman said “write the check.”

Fair enough, but the risk to mom is substantial. We are primarily responsible for the health of mom. This is really a situation where you need the OB to say something helpful other than the “non reassuring tracing, we need a section”, unfortunately the OB probably has no idea.

this is actually a situation where I think fetal tracing has a risk of really harming a mom at the expense of the baby.

 

[Arch Guillotti]

Fair enough, but the risk to mom is substantial. We are primarily responsible for the health of mom. This is really a situation where you need the OB to say something helpful other than the “non reassuring tracing, we need a section”, unfortunately the OB probably has no idea.

True. No way the OB service admitted the pt. to the ICU so presumably the medicine service knows about her so your hands are kind of tied.

 

[chessknt]

Patient went to OR without any further volume optimization as I mentioned above. Induction with aline, 0.2 mg/kg etomidate + 0.8 mg/kg propofol + sux. Pt went in to asystole within 1 minute of induction drug push, had 10 mins of CPR (epi x3 + bicarb) with ROSC. Baby out during CPR, blood loss was usual amount without significant bleeding (time from incision to closure was 25 minutes). Went to ICU on norepi + epi and was put on dobutamine and lasix gtt with significant UOP over following 24h, extubated 2d later neuro intact.

I think OR was safest place for this tough case to deliver rather than ICU because ob was able to get baby out much faster. Pt did much better after diuresis so I think if baby had been in better shape trying to diurese prior to delivery might have been the best choice but that was taken off table due to concern for baby. Tough case without a whole lot of time to act, interesting to hear others perspectives thanks all.

 

[Arch Guillotti]

Patient went to OR without any further volume optimization as I mentioned above. Induction with aline, 0.2 mg/kg etomidate + 0.8 mg/kg propofol + sux. Pt went in to asystole within 1 minute of induction drug push, had 10 mins of CPR (epi x3 + bicarb) with ROSC. Baby out during CPR, blood loss was usual amount without significant bleeding (time from incision to closure was 25 minutes). Went to ICU on norepi + epi and was put on dobutamine and lasix gtt with significant UOP over following 24h, extubated 2d later neuro intact.

I think OR was safest place for this tough case to deliver rather than ICU because ob was able to get baby out much faster. Pt did much better after diuresis so I think if baby had been in better shape trying to diurese prior to delivery might have been the best choice but that was taken off table due to concern for baby. Tough case without a whole lot of time to act, interesting to hear others perspectives thanks all.

Nice job. Thought it would be bad but not quite as you described. I would have skipped the propofol on induction. Meth and a bad heart is about as bad as it gets.

 

[coffeebythelake]

Curious... nothing here about fetal heart tones or anything.... how is the OB declaring that there is emergent?? this is all based on a sick but mostly stable mom who has altered mental status and drugged up on meth? seems like a missing part of the story here? as others have mentioned would have ideally been better optimized prior to cutting unless this was truly life threatening to mom and baby.

 

[vector2]

Patient went to OR without any further volume optimization as I mentioned above. Induction with aline, 0.2 mg/kg etomidate + 0.8 mg/kg propofol + sux. Pt went in to asystole within 1 minute of induction drug push, had 10 mins of CPR (epi x3 + bicarb) with ROSC. Baby out during CPR, blood loss was usual amount without significant bleeding (time from incision to closure was 25 minutes). Went to ICU on norepi + epi and was put on dobutamine and lasix gtt with significant UOP over following 24h, extubated 2d later neuro intact.

I think OR was safest place for this tough case to deliver rather than ICU because ob was able to get baby out much faster. Pt did much better after diuresis so I think if baby had been in better shape trying to diurese prior to delivery might have been the best choice but that was taken off table due to concern for baby. Tough case without a whole lot of time to act, interesting to hear others perspectives thanks all.

Why the propofol? Meth user with cardiomyopathy who's tachycardic and tachypneic is probably already using every nanogram of endogenous catechols in their body as is and is at high risk of decompensation with any induction method.

Still, using a bit of prop is probably OK..... but only if pushing some norepi (+- epi) beforehand.

 

[fakin' the funk]

Patient went to OR without any further volume optimization as I mentioned above. Induction with aline, 0.2 mg/kg etomidate + 0.8 mg/kg propofol + sux. Pt went in to asystole within 1 minute of induction drug push, had 10 mins of CPR (epi x3 + bicarb) with ROSC. Baby out during CPR, blood loss was usual amount without significant bleeding (time from incision to closure was 25 minutes). Went to ICU on norepi + epi and was put on dobutamine and lasix gtt with significant UOP over following 24h, extubated 2d later neuro intact.

I think OR was safest place for this tough case to deliver rather than ICU because ob was able to get baby out much faster. Pt did much better after diuresis so I think if baby had been in better shape trying to diurese prior to delivery might have been the best choice but that was taken off table due to concern for baby. Tough case without a whole lot of time to act, interesting to hear others perspectives thanks all.

This is fine care to be sure
Don't be afraid to push bicarb, pressors, inotropes, (even vaso in an EF30% if that's what it takes to maintain systemic pressure!), start infusions, etc before sketchy inductions. Think of it as preoptimization, prophylaxis.
You've repeatedly mentioned lasix and pulm edema but any volume overload in an absolute sense can't have been that substantial given that there was basically no hypoxemia and GA isn't the worst thing for fluid overload. You just had someone barely clinging on to any degree of contractile function who got sleeped

 

[Radetzky]

I don’t think there was much to optimise here beforehand. You had someone with decompensated probable meth heart (worsening sx over a week, pulmonary oedema clinically and radiologically) who was about to enter a phase of labour with both increased volume load from a contracting uterus and increased after load from pain. Wouldn’t be surprised if she arrested during labour, except it would be in a completely uncontrolled environment. Also, sure bleeding on lovenox in a Caesar is bad, but at least it’s surgically controllable, as opposed to PPH on lovenox on the labour floor.

I don’t think diuresis would have helped you much here. Sure it may have relieved some pulmonary oedema, but remember that diuresis optimises cardiac contractile function over the period of weeks. Acutely all it does is drop your CO.

ED and their obsession with pulmonary emboli drives me crazy.

 

[woopedazz]

We don't have etomidate here, so I would've gone for a simple Ketamine + Rocuronium induction; with noradrenaline trickling via a peripheral line (assuming no time to place CVC). Probably would've led to the same result.

Don't be afraid to push bicarb, pressors, inotropes, (even vaso in an EF30% if that's what it takes to maintain systemic pressure!), start infusions, etc before sketchy inductions. Think of it as preoptimization, prophylaxis.
You've repeatedly mentioned lasix and pulm edema but any volume overload in an absolute sense can't have been that substantial given that there was basically no hypoxemia and GA isn't the worst thing for fluid overload. You just had someone barely clinging on to any degree of contractile function who got sleeped

Thoughts on the utility of bicarb in this patient with a pH of 7.35?

 

[Lidolover]

We don't have etomidate here, so I would've gone for a simple Ketamine + Rocuronium induction; with noradrenaline trickling via a peripheral line (assuming no time to place CVC). Probably would've led to the same result.


Thoughts on the utility of bicarb in this patient with a pH of 7.35?

Ketamine in a catecholamine depleted pt can cause more harm than benefit (way more hypotension than you think)

Bicarb is unnecessary and also can cause more harm.

Whatever ............