Obstetric case

[woopedazz]

26 y.o. G2P1 at Term for elective cesarean section.

PMH: nil.
Meds: nil.
Illicits: nil.
NKDA
165cm tall. Booking BMI 25.

Obstetric history:

Uncomplicated 2nd pregnancy.
First delivery was an emerg section at term for foetal distress (+/- chorioamnionitis)

Seen in clinic by a colleague. They noted the following re her first cesarean:

"Spinal anaesthetic performed at [backwater hospital] without issue [dose = 11.5mg heavy bupiv +15mcg fent + 150mcg morphine = total volume ~2.9mL].
Patient became severely bradycardic immediately upon lying flat, progression to cardiac arrest shortly after, CPR for ~2mins, patient intubated, ROSC, flat baby delivered.
Extubated in ICU ~5 hours later with normal vitals, neurology, and nil further issues. Healthy baby discharged home with healthy mum 3 days later. Likely cause: high spinal given patient height."

No other documentation available. No tryptase sent/no other workup or follow-up.

Chatting to the patient she says she is very prone to fainting and says the first delivery felt like a run-of-the-mill bad fainting episode. She states she's been reviewed by cardiologists and cleared of any issues, including a Holter study. No family history of cardiac problems. Triggers are pain/smells.

No other history of note. Physical exam is thorough and wholly unremarkable. Autonomics seem fine.

ECG is NSR, rate 75. Bloods normal. CTG fine.

Patient's come in from out of town to the big OBS hospital because they're now classified as high risk.

Any concerns for this cesarean?
Anything you plan to do differently to usual?

---

Members don't see this ad.

 

[Agast]

High spinal given patient’s height? She’s 5’5” how tall do they think most women are? Sounds a lot like blaming the patient for medical error…

 

[narcotics999]

Vagal reflex and Bezold-Jarisch response.

I had a similar experience right after spinal. Not cardiac arrest, but brady enough to feel I was going to die. Tend to happen to people who have strong vagal response (past hx of fainting).

Spinal is ok. Just prepare some epi/atropine/ephedrine. Maybe use isobaric bupi.

GETA not a bad idea. BMI 25 cakewalk.

BTW, why 2.9ml?

 

[pocafx]

CSE Small spinal dose or straight epidural and titrate?

 

[Southpaw]

Chatting to the patient she says she is very prone to fainting and says the first delivery felt like a run-of-the-mill bad fainting episode. She states she's been reviewed by cardiologists and cleared of any issues, including a Holter study. No family history of cardiac problems. Triggers are pain/smells.

No other history of note. Physical exam is thorough and wholly unremarkable. Autonomics seem fine.

ECG is NSR, rate 75. Bloods normal. CTG fine.

Patient's come in from out of town to the big OBS hospital because they're now classified as high risk.

Any concerns for this cesarean?
Anything you plan to do differently to usual?

1L-2L pre op before getting to OR. Either dural puncture epidural or straight epidural dosed slower than usual for CS. Proceed once adequate levels. If you can't get them she goes to sleep - no further mucking around. Sounds like Bezold-Jarisch first time around.

 

[Hoya11]

26 y.o. G2P1 at Term for elective cesarean section.

PMH: nil.
Meds: nil.
Illicits: nil.
NKDA
165cm tall. Booking BMI 25.

Obstetric history:

Uncomplicated 2nd pregnancy.
First delivery was an emerg section at term for foetal distress (+/- chorioamnionitis)

Seen in clinic by a colleague. They noted the following re her first cesarean:

"Spinal anaesthetic performed at [backwater hospital] without issue [dose = 11.5mg heavy bupiv +15mcg fent + 150mcg morphine = total volume ~2.9mL].
Patient became severely bradycardic immediately upon lying flat, progression to cardiac arrest shortly after, CPR for ~2mins, patient intubated, ROSC, flat baby delivered.
Extubated in ICU ~5 hours later with normal vitals, neurology, and nil further issues. Healthy baby discharged home with healthy mum 3 days later. Likely cause: high spinal given patient height."

No other documentation available. No tryptase sent/no other workup or follow-up.

Chatting to the patient she says she is very prone to fainting and says the first delivery felt like a run-of-the-mill bad fainting episode. She states she's been reviewed by cardiologists and cleared of any issues, including a Holter study. No family history of cardiac problems. Triggers are pain/smells.

No other history of note. Physical exam is thorough and wholly unremarkable. Autonomics seem fine.

ECG is NSR, rate 75. Bloods normal. CTG fine.

Patient's come in from out of town to the big OBS hospital because they're now classified as high risk.

Any concerns for this cesarean?
Anything you plan to do differently to usual?

id give some glyco before
id do a 1.5ml spinal
give ephedrine right away after spinal goes in without waiting for BP

 

[patriot6]

Interesting case description, but like all OB, the plan funnels down into just a couple things. I would slowly dose an epidural to appropriate levels. But GETA is fine too. SAB is fine too now that you’re prepared with vasoactive drugs, but it’s not worth the perception of being dismissive about her prior cardiac arrest.

 

[teacher2md]

26 y.o. G2P1 at Term for elective cesarean section.

PMH: nil.
Meds: nil.
Illicits: nil.
NKDA
165cm tall. Booking BMI 25.

Obstetric history:

Uncomplicated 2nd pregnancy.
First delivery was an emerg section at term for foetal distress (+/- chorioamnionitis)

Seen in clinic by a colleague. They noted the following re her first cesarean:

"Spinal anaesthetic performed at [backwater hospital] without issue [dose = 11.5mg heavy bupiv +15mcg fent + 150mcg morphine = total volume ~2.9mL].
Patient became severely bradycardic immediately upon lying flat, progression to cardiac arrest shortly after, CPR for ~2mins, patient intubated, ROSC, flat baby delivered.
Extubated in ICU ~5 hours later with normal vitals, neurology, and nil further issues. Healthy baby discharged home with healthy mum 3 days later. Likely cause: high spinal given patient height."

No other documentation available. No tryptase sent/no other workup or follow-up.

Chatting to the patient she says she is very prone to fainting and says the first delivery felt like a run-of-the-mill bad fainting episode. She states she's been reviewed by cardiologists and cleared of any issues, including a Holter study. No family history of cardiac problems. Triggers are pain/smells.

No other history of note. Physical exam is thorough and wholly unremarkable. Autonomics seem fine.

ECG is NSR, rate 75. Bloods normal. CTG fine.

Patient's come in from out of town to the big OBS hospital because they're now classified as high risk.

Any concerns for this cesarean?
Anything you plan to do differently to usual?

How is that 2.9cc total volume? 11.5mg bupi=1.5cc, 15mcg fent= 0.3 cc, 150mcg morphine= 0.15cc.

So total should be ~2cc. Did they give 2.5cc bupi instead? If so, that would make sense that the patient had a high spinal.

 

[Planktonmd]

Prop Sux Tube...
If someone did something that almost killed that patient and her baby before, it would be crazy to try to do it again regardless of how lucky you may feel that day.

 

[abolt18]

How is that 2.9cc total volume? 11.5mg bupi=1.5cc, 15mcg fent= 0.3 cc, 150mcg morphine= 0.15cc.

So total should be ~2cc. Did they give 2.5cc bupi instead? If so, that would make sense that the patient had a high spinal.

Our duramorph is 0.5mg/mL, so 150mcg is 0.3mL. this adds a little volume, but certainly not enough to get to 2.9. Would add up to 2.1.

Perhaps they gave more of everything than OP was told. 15mg bupi, 25mcg fentanyl, and 200mcg (or 400 if it was 1mg/mL) duramorph would get you there.

 

[Southpaw]

Prop Sux Tube...
If someone did something that almost killed that patient and her baby before, it would be crazy to try to do it again regardless of how lucky you may feel that day.

Talking to the patient here is key IMO. There’s nothing wrong w GETA, but if the patient is adamant about being awake for the delivery, and plenty of them are, then you can perform neuraxial here in a safe manner.

 

[Arch Guillotti]

Vagal reflex and Bezold-Jarisch response.

This.

 

[DrAmir0078]

Spinal is ok. Just prepare some epi/atropine/ephedrine. Maybe use isobaric bupi.

What is the use of isobaric bupi here? you mean rather than heavy bupi?
Well, myself never used isobaric bupi; but a question : I have learnt here how to understand the Glass Spine theory, so when using isobaric bupi it should stay at the level of injection, isn't it? can't go cephalad to reach T4 level - based on the theory - my understanding?; and how much mg vs ml to use? Excuse my ignorance to isobaric bupi, I only use it for Regionals (it comes 20 ml 0.5%) and because of cost-effectiveness, it is expensive to use isobaric and rather we use only 0.5% heavy bupi ! .... Cheers

 

[IMGASMD]

What is the use of isobaric bupi here? you mean rather than heavy bupi?
Well, myself never used isobaric bupi; but a question : I have learnt here how to understand the Glass Spine theory, so when using isobaric bupi it should stay at the level of injection, isn't it? can't go cephalad to reach T4 level - based on the theory - my understanding?; and how much mg vs ml to use? Excuse my ignorance to isobaric bupi, I only use it for Regionals (it comes 20 ml 0.5%) and because of cost-effectiveness, it is expensive to use isobaric and rather we use only 0.5% heavy bupi ! .... Cheers

You mean 0.75% heavy bupi.
For iso bupi, I’d go with the mg equivalent. So 15mg would be 3ml.

 

[woopedazz]

For those asking about the spinal mixture:
Our heavy bupivacaine is 0.5%. they gave 2.3mL of it. I think you guys have 0.75% over there?
Fentanyl is 50mcg/mL. They gave 0.3mL or 15mcg
Morphine is 500mcg/mL. They gave 0.3mL or 150mcg.
2.9mL of solution injected.

I agree with what everyone here has said above. Pretty straightforward Vagal/BJ reflex seemed more likely to me than a high spinal.

I was pretty confident that aggressive fluid pre/co-loading and some glycopyrrolate would be sufficient to prevent it happening again. Because I'm obviously much more cleverer than those dumb backwater hospital doctors. But just to be certain I'd give some early ondansetron for the BJ and place a CSE with a low volume SAB just in case.

Wide bore cannula inserted with monitoring on. No Vagal.
1L crystalloid, ondansetron, 200mcg gylco given.
2nd litre of crystalloid commenced.
Needle-through-needle CSE. Nothing injected down the epidural catheter, just threaded and secured.
Spinal dose: 1.5mL of 0.5% bupiv heavy. 10mcg fent. 100mcg morphine.
Additional 200mcg of glyco given... Just in case...
Metaraminol infusion started (pressor with mixed direct/indirect activity; mainly alpha 1 with a bit of beta 1 in there too so you don't get quite as severe bradycardia with it. Basically weak, semi-indirect Noradrenaline).

10 minutes later:
BP remains solid, HR 90 and sinus rhythm, block to ~T5.
Surgeons teaching medical student how to put on gloves...

Suddenly patient gets agitated.
States they can't breathe and her voice is very soft.
30 seconds later begins shaking and speech becomes nonsensical.
Pupils dilated bilaterally.
Loses consciousness/response to stimulus immediately after.
Repeat BP shows a drop of ~15mmHg only. HR is now 70bpm, sinus rhythm.

Thoughts?
Hubris check?

 

[DrAmir0078]

You mean 0.75% heavy bupi.
For iso bupi, I’d go with the mg equivalent. So 15mg would be 3ml.

I had never seen 0.75%, only 0.5% heavy.
So isobaric injected at L3/L4 can head up to T4?

 

[jwk]

Prop Sux Tube...
If someone did something that almost killed that patient and her baby before, it would be crazy to try to do it again regardless of how lucky you may feel that day.

My shop would probably do a straight epidural - no CSE or funky stuff - but I think GA is a great idea. I agree doing an SAB just isn't a great idea given the history, even if you think you understand why and think you'll be prepared. IF something really bad happens to mom or baby, just go ahead and write a very large check. Your SAB will simply be indefensible with that history.

 

[MirrorTodd]

For those asking about the spinal mixture:
Our heavy bupivacaine is 0.5%. they gave 2.3mL of it. I think you guys have 0.75% over there?
Fentanyl is 50mcg/mL. They gave 0.3mL or 15mcg
Morphine is 500mcg/mL. They gave 0.3mL or 150mcg.
2.9mL of solution injected.

I agree with what everyone here has said above. Pretty straightforward Vagal/BJ reflex seemed more likely to me than a high spinal.

I was pretty confident that aggressive fluid pre/co-loading and some glycopyrrolate would be sufficient to prevent it happening again. Because I'm obviously much more cleverer than those dumb backwater hospital doctors. But just to be certain I'd give some early ondansetron for the BJ and place a CSE with a low volume SAB just in case.

Wide bore cannula inserted with monitoring on. No Vagal.
1L crystalloid, ondansetron, 200mcg gylco given.
2nd litre of crystalloid commenced.
Needle-through-needle CSE. Nothing injected down the epidural catheter, just threaded and secured.
Spinal dose: 1.5mL of 0.5% bupiv heavy. 10mcg fent. 100mcg morphine.
Additional 200mcg of glyco given... Just in case...
Metaraminol infusion started (pressor with mixed direct/indirect activity; mainly alpha 1 with a bit of beta 1 in there too so you don't get quite as severe bradycardia with it. Basically weak, semi-indirect Noradrenaline).

10 minutes later:
BP remains solid, HR 90 and sinus rhythm, block to ~T5.
Surgeons teaching medical student how to put on gloves...

Suddenly patient gets agitated.
States they can't breathe and her voice is very soft.
30 seconds later begins shaking and speech becomes nonsensical.
Pupils dilated bilaterally.
Loses consciousness/response to stimulus immediately after.
Repeat BP shows a drop of ~15mmHg only. HR is now 70bpm, sinus rhythm.

Thoughts?
Hubris check?

Get the baby out. Did she stop breathing? I'd imagine a high spinal would cause apnea as well if it's high enough to cause LOC.

 

[MirrorTodd]

I had never seen 0.75%, only 0.5% heavy.
So isobaric injected at L3/L4 can head up to T4?

That is correct.

 

[DrOwnage]

I had never seen 0.75%, only 0.5% heavy.
So isobaric injected at L3/L4 can head up to T4?

Yes 0.5% isobaric can go that high and I have had people tell me during shortages of 0.75% hyper they used isobaric and it worked fine for c sections. I always use 0.75% hyper for my sections however. I use 0.5% iso for bilateral knee replacements, slow hip ORIF surgeons, or fem bypasses and lower extremity vascular stuff.

 

[Gern Blansten]

Ondansetron 4 mg IV pre spinal to prevent Bezold -Jarisch reflex

 

[DrOwnage]

Might sound dumb but does this lady have some type of undiagnosed neurological disease? Was the opening pressure normal? Sounds like in this case it was a semi-high spinal maybe hitting lower sympathetics, but not entirely, like a horners?

Edit: For the record I would I have done almost exactly what you did minus the epidural catheter.

 

[DrAmir0078]

That is correct.

Yes 0.5% isobaric can go that high and I have had people tell me during shortages of 0.75% hyper they used isobaric and it worked fine for c sections. I always use 0.75% hyper for my sections however. I use 0.5% iso for bilateral knee replacements, slow hip ORIF surgeons, or fem bypasses and lower extremity vascular stuff.

Interesting .... I repeated the video of Glass Spine and he says "occasionally can spread higher due to some factors like coughing", I believe he said too "very difficult to go higher than T12"; But "in obstetric patients due Aorto-Caval Compression and due to engorgement of the epidural veins, may affect the isobaric and to spread higher"; he also mentioned "Due to body temperature, the isobaric might becomes hypobaric and can spread higher too".
I read an article too "body temperature would even make hyperbaric to hypobaric once it enters the SAS" - wow !
Dr. L.E.S. Carrie explained it clearly!
Thanks a lot.

 

[Southpaw]

IMO isobaric sets up slower and levels tend (but not always) to be lower. The hypotension tends to be gentler and easier to keep up with. If you’re doing it for CS, at least the formulations I’ve worked with in the US, you’ll be waiting longer than you’re used to for it to setup.

 

[Hoya11]

For those asking about the spinal mixture:
Our heavy bupivacaine is 0.5%. they gave 2.3mL of it. I think you guys have 0.75% over there?
Fentanyl is 50mcg/mL. They gave 0.3mL or 15mcg
Morphine is 500mcg/mL. They gave 0.3mL or 150mcg.
2.9mL of solution injected.

I agree with what everyone here has said above. Pretty straightforward Vagal/BJ reflex seemed more likely to me than a high spinal.

I was pretty confident that aggressive fluid pre/co-loading and some glycopyrrolate would be sufficient to prevent it happening again. Because I'm obviously much more cleverer than those dumb backwater hospital doctors. But just to be certain I'd give some early ondansetron for the BJ and place a CSE with a low volume SAB just in case.

Wide bore cannula inserted with monitoring on. No Vagal.
1L crystalloid, ondansetron, 200mcg gylco given.
2nd litre of crystalloid commenced.
Needle-through-needle CSE. Nothing injected down the epidural catheter, just threaded and secured.
Spinal dose: 1.5mL of 0.5% bupiv heavy. 10mcg fent. 100mcg morphine.
Additional 200mcg of glyco given... Just in case...
Metaraminol infusion started (pressor with mixed direct/indirect activity; mainly alpha 1 with a bit of beta 1 in there too so you don't get quite as severe bradycardia with it. Basically weak, semi-indirect Noradrenaline).

10 minutes later:
BP remains solid, HR 90 and sinus rhythm, block to ~T5.
Surgeons teaching medical student how to put on gloves...

Suddenly patient gets agitated.
States they can't breathe and her voice is very soft.
30 seconds later begins shaking and speech becomes nonsensical.
Pupils dilated bilaterally.
Loses consciousness/response to stimulus immediately after.
Repeat BP shows a drop of ~15mmHg only. HR is now 70bpm, sinus rhythm.

Thoughts?
Hubris check?

well of course you intubate at that point, but i think that there is a high chance she is crazy and maybe this is a conversion disorder

for those advocating GA: i agree it would likely be OK, but I would worry ANYTHING wrong with that baby will be blamed on the decision for GA when it wasnt truly the last resort.

 

[IMGASMD]

10 minutes later:
BP remains solid, HR 90 and sinus rhythm, block to ~T5.
Surgeons teaching medical student how to put on gloves...

Suddenly patient gets agitated.
States they can't breathe and her voice is very soft.
30 seconds later begins shaking and speech becomes nonsensical.
Pupils dilated bilaterally.
Loses consciousness/response to stimulus immediately after.
Repeat BP shows a drop of ~15mmHg only. HR is now 70bpm, sinus rhythm.

Thoughts?
Hubris check?

She’s responding appropriately now? Sat? Hand grip?

I would do exactly as what you did. Spinal and/or epidural. 12mg of bupi, little short…. Whatever the pressor of choice is running in the back.

 

[Radetzky]

well of course you intubate at that point, but i think that there is a high chance she is crazy and maybe this is a conversion disorder

for those advocating GA: i agree it would likely be OK, but I would worry ANYTHING wrong with that baby will be blamed on the decision for GA when it wasnt truly the last resort.

Pretty hard to fake bilaterally dilated pupils

 

[fittipaldi1of1]

How is that 2.9cc total volume? 11.5mg bupi=1.5cc, 15mcg fent= 0.3 cc, 150mcg morphine= 0.15cc.

So total should be ~2cc. Did they give 2.5cc bupi instead? If so, that would make sense that the patient had a high spinal.

Morphine at my place is 0.5mg/ml so 150mcg is 0.3cc

 

[Hoya11]

Pretty hard to fake bilaterally dilated pupils

lol minor detail!

 

[coffeebythelake]

Why "lay flat?"
Shouldn't you do left uterine displacement?

 

[coffeebythelake]

Ondansetron 4 mg IV pre spinal to prevent Bezold -Jarisch reflex

much evidence for this?

 

[woopedazz]

So at this point we're ~13mins post spinal.
Patient had been chatty and comfortable and perfectly normal since the SAB went in.
Vitals were stable.
Block is not above T4 (checked it at ~12minutes post spinal, which happened to coincide exactly with the weird behaviour/agitation starting)
Weird neurology started 1 minute ago with agitation/excitation; then rapidly progressed to CNS depression.
I've applied the anaesthetic mask ~30 seconds ago (as soon as she complained of SOB/soft voice) and she's an easy BVM. SpO2 100%
BP cuff ended its cycle just as the pupils start dilating in front of my eyes with a BP of ~100/55 (was ~115/65 pre SAB)
- Can I just say, watching someone's pupils dilating unexpectedly in real-time is unnerving.
Help is yet to enter the room and I'm trying to explain to the scout nurse how to open the anaethetic trolley and draw up some sux.
Tip her left lateral (even though no evidence of aortocaval compression)
Surgeons are now at the bedside and have abandoned their med student; patient already prepped and draped by the scrub nurse.
So I give the instruction to cut and continue to BVM without issue.

1-2minutes pass while scout nurse fails to get sux out.
Vitals remain stable.
HR regular in sinus rhythm.
Strong pulses at carotid + good cap refill centrally.
Help has arrived and is now drawing up suxemethonium for me.

Then... The patient starts moving her arms and resisting my jaw thrust and pushing me away.
Disorientated for about 30 seconds or so, but then basically back to normal.
She is breathing fine and asking if her baby is okay.
Vitals remain stable.
Block reassessed - never got higher than T4.
She is alert, orientated, pupils have returned to normal.
Baby delivered healthy.
Mum complains of some mild discomfort towards the end of the case, but is understanding that I'm not going near that CSE with a 12 foot pole.
Spinal wears off in recovery.

The next day she is completely back to normal. It was just <5minutes of WTF is happening.
She recalls events clearly up until blacking out with the mask already applied to her face.
She says it was "nothing like anything she's ever experienced before" and not a usual syncope reaction.
She says she remembers being unable to breathe easily and feeling locked in just before blacking out.

Bloods taken (including tryptase, because I just don't have a clue what happened here...) --> all normal.
Referred to neuro --> outcome pending.
Told to never have any neuraxial procedure ever again unless a cause is found.

So I ask.
WTF happened here? I have no idea...

EDIT:
SAB was injected incredibly slowly and patient was never head down. I was actually pretty concerned that I was being too cautious and the block wouldn't get high enough.
My presumption is I've missed something. Perhaps the BP cuff didn't pick up one outrageously low BP just as symptoms were progressing? Perhaps it misread? Perhaps there was some weird seizure thing? I got nothing...

 

[PainDrain]

Vagal reflex and Bezold-Jarisch response.

This 100%. There is a paper I read a while back that showed severe bradycardia and hypotension under spinal (and CV collapse) was more common in those with baseline low resting HR and/or BP. This is likely a woman with high baseline vagal tone and when the spinal hits the sympathetic fibers then it leads to a profound response. I have had this happen a handful of times and I don’t think my sphincter tone has recovered.

 

[anaesthetic]

This 100%. There is a paper I read a while back that showed severe bradycardia and hypotension under spinal (and CV collapse) was more common in those with baseline low resting HR and/or BP. This is likely a woman with high baseline vagal tone and when the spinal hits the sympathetic fibers then it leads to a profound response. I have had this happen a handful of times and I don’t think my sphincter tone has recovered.

For sure. Maybe related, but I did a CABG on a marathon runner who got severe bradycardia and hypotension (ie., a few beats away from asystole) with sternal retraction. Told the surgeon, “He’s not really liking that,” so he looked up, let off, got nervous, and pressed on the heart a couple of times for good measure. Patient did great.

 

[Arch Guillotti]

This 100%. There is a paper I read a while back that showed severe bradycardia and hypotension under spinal (and CV collapse) was more common in those with baseline low resting HR and/or BP. This is likely a woman with high baseline vagal tone and when the spinal hits the sympathetic fibers then it leads to a profound response. I have had this happen a handful of times and I don’t think my sphincter tone has recovered.

It is an APSF paper put out years ago.

 

[deleted875186]

This sounds like a reflex, I would have thought vasovagal, or Bezold Jarish as noted above. I believe dilated pupils can occur with vasovagal. I would have thought conversion disorder but the lack of muscle tone with bag mask and pupils seem to seal the deal.

Perhaps neuro could do a tilt table test, probably this patient gets a full cardiac workup, honestly don’t know what else to do. The lack of patient history of similar events seems unusual.

 

[deleted875186]

bezold Jarisch is strong in young people. I did a spinal in residency for a young guy for something orthopedic lower extremity, couple hour case, used bupi, took him off the low dose phenylephrine I had him on, rolled over to PACU, maybe 10 mins later, just sitting him up caused a profound Brady and hypotension.

 

[deleted875186]

Now that I’m thinking about it, I thought the spinal anesthesia bradycardia was the “reverse brainbridge reflex”

 

[woopedazz]

The issue I have is:

The BP and HR were good.

 

[deleted875186]

The issue I have is:

The BP and HR were good.

Maybe not, it’s an non invasive BP, takes a while to cycle, it’s inaccurate. After brief low flow during a vasovagal patients can be post ictal like state despite good perfusion.

 

[PainDrain]

Not sure if it’s the same paper Arch mentioned and I referred to earlier but there is published evidence that CV collapse is also more common after spinal in those who are nervous pre op.

 

[MirrorTodd]

The issue I have is:

The BP and HR were good.

What was the time interval for BP? I don't think you're gonna get a satisfactory answer honestly. I suppose it is possible that in the time frame from the BP machine reading to her going unconscious, her BP dropped but I think we can all agree that is probably not very likely.

 

[DrOwnage]

Ask this lady to come back and inject normal saline into her spine. Do it for science.

 

[Radetzky]

Sounds like syncope. The time course alone rules out a high spinal. How low did the HR get?

 

[LivetoTell]

Like ARCH and others have stated there is a paper out addressing this issue. Mainly in young people, with ephedrine being the drug of choice I believe. Later, Zofran came to light in somehow decreasing these events from occurring.

 

[Gern Blansten]

much evidence for this?

Several papers. Here’s one:

Effect of Intravenous Ondansetron on Spinal Anesthesia-Induced Hypotension and Bradycardia: A Randomized Controlled Double-Blinded Study

Spinal anesthesia is a safe anesthetic technique commonly practiced. However, it is associated with hypotension (33%), bradycardia (13%), and shivering which are induced by hypovolemia, sympathetic blockade, and Bezold–Jarisch reflex through intracardiac ...

www.ncbi.nlm.nih.gov

“Spinal anesthesia is a safe anesthetic technique commonly practiced. However, it is associated with hypotension (33%), bradycardia (13%), and shivering which are induced by hypovolemia, sympathetic blockade, and Bezold–Jarisch reflex through intracardiac serotonin (5HT3) receptors and vagus nerve.”

Ondansetron is a 5HT3 blocker and is therefore fairly effective, apparently.

 

[PainDrain]

Several papers. Here’s one:

Effect of Intravenous Ondansetron on Spinal Anesthesia-Induced Hypotension and Bradycardia: A Randomized Controlled Double-Blinded Study

Spinal anesthesia is a safe anesthetic technique commonly practiced. However, it is associated with hypotension (33%), bradycardia (13%), and shivering which are induced by hypovolemia, sympathetic blockade, and Bezold–Jarisch reflex through intracardiac ...

www.ncbi.nlm.nih.gov

“Spinal anesthesia is a safe anesthetic technique commonly practiced. However, it is associated with hypotension (33%), bradycardia (13%), and shivering which are induced by hypovolemia, sympathetic blockade, and Bezold–Jarisch reflex through intracardiac serotonin (5HT3) receptors and vagus nerve.”

Ondansetron is a 5HT3 blocker and is therefore fairly effective, apparently.

Should also mention that profound serotonin release and it’s effect on the heart has been implicated in the CV collapse seen with an amniotic fluid embolus. There are case reports of treating AFE with zofran and metoclopramide.

 

[Gern Blansten]

Should also mention that profound serotonin release and it’s effect on the heart has been implicated in the CV collapse seen with an amniotic fluid embolus. There are case reports of treating AFE with zofran and metoclopramide.

Are you talking about the atropine, ondansetron, ketorolac (A-OK) treatment?
There is also a case report for treatment with lipid emulsion that explains why the components of lipid emulsion have an inotropic effect and are protective.
C1 esterase inhibitor concentrate also has a case report of its successful use.
The AOK tx plan, I can only find a SOAP abstract. I have never found an actual published case report. They list a believable mechanism, but not sure it’s been proven. Since mortality is so high and conventional treatments are frequently futile, trying something different is justifiable, IMHO.

 

[anbuitachi]

it sounds like she had a mental breakdown for a few minutes. anxiety causes pupillary dilation. explains everything. anxiety can also change voice

 

[Beeftenderloin]

it sounds like she had a mental breakdown for a few minutes. anxiety causes pupillary dilation. explains everything. anxiety can also change voice

Taking it back to med school: anxiety/fight or flight response > intrinsic epi release > activation of a1 receptors on the iris dilators > mydriasis.