OB case

[PainDrain]

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?

Agree with others above. I find ketamine in catecholamine depleted states can have a seriously detrimental effect. In cases such as above I go with a healthy dose of norepi pre induction, start an infusion, give some opiate and benzo; rarely etomidate.

I find no need for bicarb unless the pH is very low (7.1) and I suspect the myocardial contractility is being depressed by profound acidosis.

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[woopedazz]

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

Yeah, but what would you use instead? It's not a cold tube, they're allowed to be induced.
Benzo, opioid cardiac induction always makes me a bit hesitant in obs

Bicarb is unnecessary and also can cause more harm.

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

I agree...? Hence querying the quoted text.

 

[Southpaw]

A lot that’s strange and/or unanswered about that case. But that’s ob for ya!

 

[Mman]

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 ............

Ketamine is going to cause less of a problem than an equipotent dose of propofol

 

[GassYous]

I wouldn't give any prop here. versed sux cut!

 

[anbuitachi]

Agree w rest. Don't know why the heavy induction of .2 etomidate and .8 propofol.....

Skip the propofol. Etomidate is enough.
.8 of propofol is what? 80mg??? How big is this lady

What is maintenance anesthesia?

 

[Arch Guillotti]

What is maintenance anesthesia?

Hypoxia and hypotension.

 

[OTCAwesome]

I wouldn't give any prop here. versed sux cut!

100% agree with you. Not sure what the problem is with just versed and paralytic, that's my go to for my cardiac patients who are actively trying to die.

 

[Lidolover]

100% agree with you. Not sure what the problem is with just versed and paralytic, that's my go to for my cardiac patients who are actively trying to die.

The problem is the fetus.

 

[deleted162650]

The problem is the fetus.

You worried about causing a cleft lip/palate at 36wks??

 

[Arch Guillotti]

The problem is the fetus.

I would prefer not having to code the mom though.

 

[GassYous]

The problem is the fetus.

The fetus that has been exposed to meth and god knows what else throughout the pregnancy?

 

[Lidolover]

Haha! Love your reaction! Since the entire case is messed up from the get go let’s not end it with a neonatal code for resp failure etc

 

[deleted162650]

Haha! Love your reaction! Since the entire case is messed up from the get go let’s not end it with a neonatal code for resp failure etc

The kid is all hopped up on meth. It needs a little midaz to balance out.

 

[GassYous]

The kid is all hopped up on meth. It needs a little midaz to balance out.

Hes had so much meth he doesn't even have any teeth!

 

[Ronin786]

A patient like this belonged in an ICU before going to the OR. Can just imagine the **** show between OB and Cards. 100% one of the scenarios where somebody has to step in (usually anesthesiologist) and come up with a cohesive plan.

Alls well that ends well I guess, but seems like a very rushed OR job when patience may have allowed for a lot more controlled scenarios.

 

[GassYous]

A patient like this belonged in an ICU before going to the OR. Can just imagine the **** show between OB and Cards. 100% one of the scenarios where somebody has to step in (usually anesthesiologist) and come up with a cohesive plan.

Alls well that ends well I guess, but seems like a very rushed OR job when patience may have allowed for a lot more controlled scenarios.

I'm not sure that a coding patient is ending well

 

[Mman]

A patient like this belonged in an ICU before going to the OR.

the initial post states they were admitted to the ICU

 

[anbuitachi]

there are many ways to induce this lady... whatever it is, just dont give a lot of it. there's a preinduction arterial line.. can go slow if needed. dont need to slam everything in in this patient, despite pregnant

 

[deleted162650]

dont need to slam everything in in this patient, despite pregnant

Isn’t that what got her into this mess in the first place??

 

[deleted697535]

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 ............

Agree with others above. I find ketamine in catecholamine depleted states can have a seriously detrimental effect. is.

What is a catecholamine deplete patient?

Ive heard smart people tell me this a lot but never found anything bar the worst evidence possible for it. Those smart people turned out to be absolute idiots that couldnt butter bread in the end, which makes sense. Not saying any of you are the aforementioned btw

My 2 tamponades and 1 type A on last weeks call shift did fine with ketamine and id imagine they were reasonably catecholamine deplete. Now i only work in a crappy 2000 pump's a year cardiac centre so i didnt measure their catecholamine level pre induction so shame on me really. maybe they had loads of catechoalamines floating around in the litre of blood in their pericardium(s)

 

[deleted697535]

I'm not sure that a coding patient is ending well

Yeah this sounds like an absolute disaster that youre screwed if you do or you dont...
a coding parturient is the worst outcome most anesthesiologists could imagine. overall it sounds like both patient and baby came out reasonably unharmed so well done on that

but overall this sounds like a disaster of a case.

 

[PainDrain]

What is a catecholamine deplete patient?

Ive heard smart people tell me this a lot but never found anything bar the worst evidence possible for it. Those smart people turned out to be absolute idiots that couldnt butter bread in the end, which makes sense. Not saying any of you are the aforementioned btw

My 2 tamponades and 1 type A on last weeks call shift did fine with ketamine and id imagine they were reasonably catecholamine deplete. Now i only work in a crappy 2000 pump's a year cardiac centre so i didnt measure their catecholamine level pre induction so shame on me really. maybe they had loads of catechoalamines floating around in the litre of blood in their pericardium(s)

Well, tell me how it is ketamine maintains hemodynamics during induction? What are its direct cardiovascular effects?

 

[Arch Guillotti]

What is a catecholamine deplete patient?

Ive heard smart people tell me this a lot but never found anything bar the worst evidence possible for it. Those smart people turned out to be absolute idiots that couldnt butter bread in the end, which makes sense. Not saying any of you are the aforementioned btw

My 2 tamponades and 1 type A on last weeks call shift did fine with ketamine and id imagine they were reasonably catecholamine deplete. Now i only work in a crappy 2000 pump's a year cardiac centre so i didnt measure their catecholamine level pre induction so shame on me really. maybe they had loads of catechoalamines floating around in the litre of blood in their pericardium(s)

Bully for you.

No offense but I suggest you do some reading, it's a very real phenomenon.

 

[deleted697535]

Yes. A shocked patient arrests during a precarious induction that happened to have ketamine plus 500 other variables going on that no one measures or blinds or controls for with a gold standard.

Well im convinced.

 

[Hork Bajir]

@Newtwo you might want to consider whether you are falling victim to Dunning-Krueger here. Not sure what you’re like in real life (hard to tell in an anonymous internet forum), but there is a difference between confidence taking care is sick patients and hubris- your posts here sound more like the latter than the former. No offense intended, of course, just an observation.

I can tell you that ketamine absolutely does cause myocardial depression. If you haven’t seen it yet, it only means you haven’t given ketamine to enough very sick patients. Totally fine to question dogma, but I don’t think you can extrapolate your n = 3 cases last weekend to decide that a well known and widely accepted property of a drug is just made up hooey.

 

[IlDestriero]

I think I would have done the cardiac style induction with midazolam fentanyl etomodate Epi and just had the NICU attending there to tube the baby if it came out depressed. Norepinephrine running pre induction.
What a disaster.
As for the cut in 30 min or write the check if the kid doesn’t get into Harvard, I’m not so sure it’s that black and white in a patient like this. Similar to a crash section in a morbidly obese difficult airway patient, you don’t just prop-sux-assassinate the mom because of “non reassuring fetal heart tones” the mother is your patient.

 

[Beeftenderloin]

I’m still sitting here trying to wrap my head around why a full induction dose of etomidate AND propofol was given? The etomidate alone would have been more than sufficient, and honestly I probably would have used closer to 0.1mg/kg. Adding a double dose of prop on top of a more than sufficient dose of etomidate is what made her code. Yes, I said double dose of prop. Patients with severely reduced EF need WAY less prop than people think. You can induce some of these sick heart as little as 2-3cc of prop, you just need to give it more time to circulate with that reduced CO. If you’re gonna blast a patient like this on induction you gotta know they’re gonna require some serious hemodynamic support along with it.

 

[Twiggidy]

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.

Easy case. Intubation. C-section. ICU with lines so they don't bother me for anything else.

Edit: Reading back on the induction issue now. As said above, it's a "cardiac style" RSI. You don't need anything more than some etomidate or propofol to get her to sleep. I really think this is something that is either forgotten or isn't taught enough in residency. You don't need the full 20cc propofol (or 10cc etomidate) to get most people sleeping. Plus her mental status is already 50/50. I'm not concerned about "intubation awareness" if anything, you DL-ing her "light" is probably going to help with the hemodynamics and in turn help perfusion to the placenta

 

[coffeebythelake]

I’m still sitting here trying to wrap my head around why a full induction dose of etomidate AND propofol was given? The etomidate alone would have been more than sufficient, and honestly I probably would have used closer to 0.1mg/kg. Adding a double dose of prop on top of a more than sufficient dose of etomidate is what made her code. Yes, I said double dose of prop. Patients with severely reduced EF need WAY less prop than people think. You can induce some of these sick heart as little as 2-3cc of prop, you just need to give it more time to circulate with that reduced CO. If you’re gonna blast a patient like this on induction you gotta know they’re gonna require some serious hemodynamic support along with it.

Add on top of this patients marginal mental status and the term pregnancy both of which should reduce your anesthetic requirements.

 

[Twiggidy]

This is what happens when any pregnant patient that ISN'T the normal 30 year old yoga mom ASA 2 arrives to the hospital

I understand the concerns for "baby" (see what I did there? i hate on L&D that they don't say "the baby"). Most "high risk OB" is cardiac in nature so you're basically talking about a cardiac patient with an alien in their stomach, but regardless, treat them like a CARDIAC patient, especially in an emergency/urgency.

So, if a 70 year old with severe MR due to a ruptured and an EF of 20% arrives at your OR for an MVR and just so happens to have Quato in his stomach, how do you put the patient to sleep? It's the same way you put this 25 year old meth head with Quato in her stomach to sleep. It's evil to say, but the alien isn't your concern but rather THE HOST is your concern.

 

[nimbus]

Easy case. Intubation. C-section. ICU with lines so they don't bother me for anything else.

Edit: Reading back on the induction issue now. As said above, it's a "cardiac style" RSI. You don't need anything more than some etomidate or propofol to get her to sleep. I really think this is something that is either forgotten or isn't taught enough in residency. You don't need the full 20cc propofol (or 10cc etomidate) to get most people sleeping. Plus her mental status is already 50/50. I'm not concerned about "intubation awareness" if anything, you DL-ing her "light" is probably going to help with the hemodynamics and in turn help perfusion to the placenta

Yep. You don’t need any more than you need for a cardioversion.

 

[GassYous]

Easy case. Intubation. C-section. ICU with lines so they don't bother me for anything else.

Edit: Reading back on the induction issue now. As said above, it's a "cardiac style" RSI. You don't need anything more than some etomidate or propofol to get her to sleep. I really think this is something that is either forgotten or isn't taught enough in residency. You don't need the full 20cc propofol (or 10cc etomidate) to get most people sleeping. Plus her mental status is already 50/50. I'm not concerned about "intubation awareness" if anything, you DL-ing her "light" is probably going to help with the hemodynamics and in turn help perfusion to the placenta

In residency the attendings would teach residents to have 2 sticks of propofol ready for every case. What a waste of plastic and medication. If you have a 50 kg 90 year old you don't need to draw up more than 5 ccs. A bunch of my compatriots will still draw up 10 different labeled syringes and take 15 minutes to set up their room when I'm done in less than 3 using one induction syringe with much less waste and fuss.

 

[coffeebythelake]

In residency the attendings would teach residents to have 2 sticks of propofol ready for every case. What a waste of plastic and medication. If you have a 50 kg 90 year old you don't need to draw up more than 5 ccs. A bunch of my compatriots will still draw up 10 different labeled syringes and take 15 minutes to set up their room when I'm done in less than 3 using one induction syringe with much less waste and fuss.

For a young patient 2 sticks of propofol isn't a bad idea. Also.. part of this might be hedging in case patient is unexpectedly difficult to intubate and need to troubleshoot (something not entirely out of realm of possibility with trainees). Propofol treats hypertension when the trainee takes their sweet time and is forceful with their technique