You have just started a shift in Obstetrics and are called to assess a 32 year old G1P0 at 35 weeks for an urgent section for HELLP complicated by non-reassuring fetal heart. She has in indwelling epidural catheter placed by a colleague at an early stage of labour 14 hours previously. How would you assess the patient?
Signs symptoms of bleeding, Liver function issues?, HTN and symptoms/treatments
Headaches/visual changes/neurochanges, Mg?
Recent trace?, Severity of fetal condition
Complications of pregnancy, Fetal anomalies?
Onset/stage/symptoms (Frequency of contractions- interventions)
Difficulties in placement, Efficacy/quality of block, Complications, Top up’s and infusions
PMH, Meds/allergies, FH, PAH
Airway, CVS, Resp, Height of block, Epidural insertion site
Review most recent US (Placental position), CBC, PLATLETs, LFT’s
Consider coags/DIC screen as indicated by history
You learn that the patient is a known difficult airway (previously requiring an awake intubation for a remote surgical procedure), but was otherwise previously healthy. She is small in stature and only 50 kg despite her late stage of pregnancy. She has mandibular hypoplasia with only 1 finger TM distance, full teeth and a MP 4. Her epidural has been running for the past 14 hours (10 cc’s per hour of 0.1% bupivacaine + 2 ucg/kg fentanyl) and she’s had 3 recent top up’s of 10cc’s of 0.25% bupivacaine (over the past 4 hours). She has a bilateral sensory block to T9. A recent CBC shows a platelet count of 25,000 (previously 80,000 2 hours ago). How would you provide anesthesia?
Should recognize the conflicting concerns and options for anesthesia
Of major concern here would be
Complicating the risk of PPH and C/S as well as increasing the risk of placing spinal
Potentially impossible airway
Making an RSI contraindicated
Low body weight and high dose of local anesthesia
Patient at risk for LA toxicity particularly if topicalizing the airway or topping up the epidural
Need for intra-uterine resuscitation
Should optimize for the C/S appropriately by
Transfusion platlets to target >50
Preparing for massive transfusion (RBC/FFP/etc)
Preparing for PPH
Provide intra-uterine resuscitation (LLD position) with Continuous fetal monitoring
Provide Reflux prophylaxis
Candidate shoulder discuss the pros/cons of their approach. LAST should be considered with use of epidural or airway topicalization. If regional chosen, must have appropriate strategy for peri-procedure capture of airway. Should be adequately prepared for massive transfusion. Consider the main OR for management.
You proceed as planned. As you turn to prepare the oxytocin for administration you see ventricular tachycardia on the monitor. You turn and find the patient unresponsive and pulseless. You begin CPR but get no chest rise. How would you proceed?
ACLS unstable VTach. Immediate defib, epi and ongoing CPR. Perimortum delivery
Should highly consider LA toxicity in this instance and prioritize
Administration of Intralipid
Delivery of chest compressions
Delivery of fetus (4 mins)
Recognize potential difficult ventilation
Call for help (declare potential CICO)
Attend to ETT (if present) assess for
Consider bronch to assess position
Assess for obstruction
Consider removing if not present and proceed to support ventilation and oxygenation through a protocolized approach (see lifelines)
Should be considered and described if necessary