UBP 5.2 (Long Form): Trauma – Obstetric Patient

Question 1

Intra-operative Management:

Would you recommend the administration of magnesium?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5^th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 1

While this patient’s headache, high blood pressure, proteinuria, and low platelets may have all resulted from her trauma, they could also be manifestations of – preeclampsia, placing the patient at risk for eclampsia and seizure.

Therefore, if additional lab work supported the diagnosis of preeclampsia (elevated serum urate and liver enzyme levels would support the diagnosis), I would recommend the administration of magnesium, despite the fact that it could have some potentially deleterious cardiac effects (i.e. hypotension, bradycardia, complete heart block, and cardiac arrest) and could complicate the ongoing assessment of her mental status (magnesium can lead to CNS depression).

Magnesium administration would reduce the risk for eclamptic seizures in a patient who may already be at risk for cerebral ischemia, due to elevated intracranial pressure (headache after head trauma), anemia (vaginal bleeding with potentially significant occult blood loss), and hypovolemia (leading to reduced perfusion pressure).

Moreover, given her obesity, pregnancy, swollen tongue, loose teeth, bloody oropharynx, and C-collar, I would be very concerned about the difficulty of emergent airway management, as would be required should she develop a seizure.

Question 2

Intra-operative Management:

The obstetrician asks if you’re planning regional anesthesia for the case. What would you say?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 2

While utilizing regional anesthesia may obviate the need for general anesthesia and airway manipulation of this patient with a potentially difficult airway (obesity, pregnancy, swollen tongue, loose teeth, bloody oropharynx, C-collar, and possible preeclampsia), it would NOT be my first choice given the considerable risks associated with neuraxial anesthesia in this particular case.

1. First, the skin dimple and tuft of hair over her 5^th lumbar vertebrae is often associated with an underlying spinal cord abnormality (i.e. tethered cord), placing her at increased risk for dural puncture and direct neural trauma during neuraxial anesthetic placement (an epidural is safer than a spinal, but without an MRI of the spinal cord, it is best to avoid neuraxial anesthesia, if possible).
2. Second, given the potential presence of preeclampsia, significant occult blood loss, and abruption, she is at increased risk of developing a coagulopathy, placing her at increased risk for epidural hematoma.
3. Third, her anemia and probably hypovolemia (secondary to preeclampsia and/or occult blood loss) place her at increased risk for uteroplacental insufficiency and end-organ ischemia following the sympathectomy associated with neuraxial anesthesia.
4. Finally, her head trauma may have resulted in elevated intracranial pressures, placing her at risk for cerebral ischemia (if a rapid sympathectomy resulted in hypotension) and brain stem herniation (Theoretically, the loss of cerebral spinal fluid from the spinal compartment, in the presence of increased ICP, could lead to a life-threatening pressure gradient between the cerebral and spinal compartments).

However, my final anesthetic choice would be made weighing the risks of regional anesthesia against the risks of general anesthesia, always keeping in mind the urgency of the case and the risks to the baby.

Question 3

Intra-operative Management:

By the time you get to the operating room, the mother’s blood pressure is 84/52 mmHg. The obstetrician suspects worsening placental abruption and wants to proceed with emergency cesarean section. You decide to provide general anesthesia for the case. Would ketamine be a good choice for intubation and induction?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 3

Ketamine would be a reasonable choice for this hypotensive patient with a potentially difficult airway (c-collar, large swollen tongue, blood in oropharynx, and multiple loose teeth) due to its sympathomimetic properties and low respiratory depressant effects.

However, ketamine could potentially result in direct myocardial depression (when catecholamines are depleted), increased ICP (which may be of concern in this patient with head trauma and a headache), emergence delirium and hallucinations (which may confuse any ongoing assessment of her neurologic status), and neonatal depression (associated with doses > 1 mg/kg).

Therefore, considering these potential complications along with her potential for difficult airway management,

I would prefer to perform an awake intubation or obtain a surgical airway prior to induction.

Question 4

Intra-operative Management:

She is not yet intubated, and The baby’s heart tones go down. What will you do?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 4

I would immediately attempt to optimize the mother’s condition (recognizing that this is also the most effective means of improving the baby’s condition), and prepare for emergency cesarean section.

To this end, I would:

1. apply 100% oxygen;
2. auscultate the chest to ensure bilateral breath sounds, recognizing that her rib fractures or central line placement may have resulted in a tension pneumothorax;
3. evaluate the ECG;
4. ensure adequate left uterine displacement;
5. administer fluids and vasopressors to reestablish adequate perfusion pressure;
6. call for a surgeon capable of obtaining a surgical airway;
7. prep, drape, and inject local anesthetic in preparation for tracheostomy;
8. ensure the presence of difficult airway equipment; and
9. verify that the patient is typed and crossed, and notify the blood bank of a possible massive blood transfusion.
10. Once a surgical airway was secured, I would – induce the patient utilizing a titrated amount of etomidate, opioids, and volatile agents, as tolerated.
11. I would then – notify the neonatologist that the neonate might experience opioid-induced respiratory depression (which can be reversed with naloxone).
12. While the surgery proceeded, I would – order an ABG (acidosis would lead to cardiovascular depression), electrolytes, a hemoglobin and hematocrit, and coagulation profile (patient at increased risk for thrombocytopenia and/or DIC).
13. Finally, if not already done in the trauma suite, I would – consider inserting a pulmonary artery catheter and/or obtaining an echocardiogram to further evaluate cardiac function and rule out myocardial infarction or cardiac tamponade.

Question 5

Intra-operative Management:

The mother is intubated and stable; the baby is delivered. What is the difference between omphalocele and gastroschisis?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 5

Both congenital disorders are more likely to occur in males and are characterized by abdominal wall defects that allow for the external herniation of abdominal viscera.

Omphalocele occurs when then gut fails to return to the abdominal cavity during gestation, whereas, gastroschisis results when occlusion of the omphalomesenteric artery leads to abdominal wall defect, with subsequent herniation of the abdominal contents through the defect.

An omphalocele occurs at the base of the umbilicus, has a membranous covering around the herniated viscera (protective against infection and loss of extracellular fluid), usually involves normally functioning bowel, and is often associated with congenital defects such as – diaphragmatic hernia, trisomy 21, exstrophy of the bladder, and cardiac abnormalities.

A gastroschisis usually occurs lateral to the umbilicus, involves exposed viscera and intestines (increased risk for infection and loss of extracellular fluid), involves inflamed and functionally abnormal bowel, and is less likely to be associated with congenital abnormalities.

Question 6

Intra-operative Management:

The neonate has a large omphalocele. How would you prepare him for surgery?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 6

GIven the risks associated with omphalocele and externalized abdominal contents, I would:

1. address any respiratory insufficiency (babies are often premature and omphalocele is sometimes associated with lung hypoplasia and abnormal thoracic development);
2. cover the externalized viscera with sterile, saline-soaked dressings, and then wrap them in plastic to minimize fluid and temperature loss;
3. prevent infection;
4. maintain normothermia;
5. obtain adequate intravenous access (umbilical artery catheterization is relatively contraindicated);
6. optimize the baby’s fluid (replace lost fluids with lactated ringers and 5% albumin – the latter is utilized to maintain normal oncotic pressure), electrolyte, and acid-base status;
7. decompress the stomach with an orogastric tube, to decrease the risk of regurgitation and pulmonary aspiration; and
8. delay surgery until the baby is stabilized and a complete assessment for associated congenital abnormalities can be performed (including an echocardiogram to identify cardiac abnormalities).

Question 7

Intra-operative Management:

What is Beckwith-Wiedemann syndrome?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 7

Beckwith-Wiedemann syndrome is a disorder associated with

a small number of babies with omphalocele,

characterized by macrosomia (birth weight and length > 90^th percentile),

macroglossia,

midline abdominal wall defect (i.e. omphalocele, umbilical hernia),

ear creases / ear pits,

neonatal HYPOglycemia, and

polycythemia (hyperviscosity).

Given this association, anesthesiologists should recognize the potential for difficult airway management secondary to macroglossia, and make the appropriate preparations.

Question 8

Post-operative Management:

The neonate presents for repair of omphalocele after the appropriate preoperative preparation. What monitoring would you require?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 8

My monitoring for this case would include – an ECG, end-tidal CO2, blood pressure cuff, inspiratory oxygen, an esophageal or axillary temperature probe (these neonates are more susceptible to heat loss due to the herniated abdominal viscera), and a precordial and/or esophageal stethoscope to aid in monitoring of his cardiopulmonary status.

Moreover, given the potential for significant fluid loss during this case, I would place – arterial line for blood pressure monitoring and frequent arterial blood gas monitoring to assess his acid-base status.

I would also carefully monitor his airway pressures as a means of identifying any reduction in pulmonary compliance, which may occur during the reduction of herniated abdominal viscera (due to decreased diaphragmatic excursion).

Since muscle relaxation is required to facilitate abdominal closure, I would utilize a peripheral nerve stimulator for neuromuscular monitoring.

Finally, recognizing that markedly increased intraabdominal pressures following abdominal closure can impair circulation to the bowel, kidneys, and lower extremities (compression of the inferior vena cava leads to decreased venous return from the lower body, lower extremity congestion, and cyanosis), I would place an additional pulse oximeter on his foot to monitor lower extremity circulation.

Question 9

Post-operative Management:

How would you intubate this baby?

(Baby has large omphalocele in need of repair)

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 9

Recognizing the potential for associated congenital anomalies (i.e. macroglossia) and difficult airway management, I would first perform a careful airway exam.

I would then ensure the presence of the appropriate airway equipment, intravenous access, and monitoring.

Next, given the increased risk of regurgitation and pulmonary aspiration, I would decompress the baby’s stomach with a nasogastric tube and, assuming the airway exam was reassuring, perform a rapid sequence induction, securing the airway with an appropriately sized, cuffed endotracheal tube

(may require higher peak inspiratory pressures due to impaired diaphragmatic excursion following the reduction of herniated abdominal viscera).

Alternatively, I could perform an awake intubation, which would also reduce the risk of regurgitation and pulmonary aspiration.

Question 10

Post-operative Management:

Would you employ nitrous oxide as part of your anesthetic?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 10

I would NOT employ nitrous oxide since it may diffuse into the intestinal tract, leading to significant bowel distention, which could then inhibit reduction of the herniated abdominal viscera.

However, recognizing that the use of 100% oxygen may place this premature neonate at increased risk for retinopathy of prematurity (less than 44 weeks gestation), I would – utilize air to reduce my oxygen concentration as much as would be tolerated, depending on the cardiopulmonary status of the baby

(frequently sited targets are an oxygen saturation of about 92-96% and a Pao2 of about 60-70 mmHg).

In order to further reduce the risk of retinopathy of prematurity, I would avoid major fluctuations in oxygen levels, anemia, hypercarbia, and acidosis.

Question 11

Post-operative Management:

All intestines and viscera are returned to the abdominal cavity and the pulse-oximeter on the neonate’s foot begins reading significantly lower than a pulse-oximeter on his right upper extremity.

What do you think is going on?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 11

This difference in pulse-oximetry readings from the upper extremity to the lower extremity is consistent with impaired lower extremity perfusion occurring secondary to compression of the inferior vena cava following the reduction of his eviscerated abdominal contents

(increased abdominal pressures → cephalad movement of the diaphragm → increased thoracic pressures → compression of the inferior vena cava → increased venous congestion and reduced cardiac output → lower extremity hypoxia and a decreased pulse oximeter reading.

Increased abdominal pressures leading to compression of the aorta and systemic vasculature may also contribute to lower extremity hypoxia).

However, I would also consider other potential causes such as – equipment error, an inflated blood pressure cuff on the same lower extremity as the pulse oximeter, or right-to-left shunting through a patent ductus arteriosus (preductal oxygen saturation, as would be monitored on the upper extremity, is relatively higher than post-ductal oxygen saturation, that would be monitored on the lower extremity).

If it were determined that increased intra-abdominal pressures were leading to decreased lower extremity perfusion and oxygenation, it would be necessary to remove the abdominal contents and perform a staged closure.

Question 12

Post-operative Management:

When is a staged closure indicated?

(for omphalocele repair)

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 12

It may be necessary to plan a staged reduction (utilizing a Dacron Silastic silo) when the primary reduction of the herniated abdominal contents leads to markedly increased intra-abdominal pressures, with subsequent impaired ventilation and decreased intestinal, renal, hepatic, and lower extremity perfusion.

Measurements of intragastric (utilizing a nasogastric tube) or bladder pressures after reducing the eviscerated abdominal contents have been used to determine the need for a staged closure.

Some suggested criteria for a staged closure include intragastric or intravesical pressure > 20 cm H20, peak inspiratory pressure > 35 cm H2O, or an end-tidal carbon dioxide level > 50 mmHg.

Question 13

Post-operative Management:

A staged closure is indicated and a Silastic silo is placed. Would you extubate the baby at the end of the procedure?

• (A 5’3”, 102 kg, 24-year-old, pregnant female (G1P0) at 36 weeks gestation is brought to the obstetric suite for delivery following a motor vehicle accident. She has had no prenatal care, and was brought to the hospital after being involved in a motor vehicle accident where her husband rear-ended another car at about 45 miles/hour. She doesn’t remember anything after hitting her head on the passenger side dash at impact. On exam, she is alert, oriented, and complaining of abdominal pain and a headache. A central line has been placed in the right internal jugular vein and she is ready for transfer to the obstetric suite for urgent cesarean section.*
• PMHx: Spina Bifida*
• Anesth Hx: None*
• Meds: None*
• Allergies: NKDA*
• PE: Vital Signs: P = 124, R = 24, BP = 162/96 mmHg, O2 sat = 98% on non-rebreathing mask, T = 36ºC*
• Airway: blood in oropharynx; multiple loose teeth; unable to determine Mallampati score due to large swollen tongue, which appears to have been bitten; c-collar in place (unable to clear due to distracting pain)*
• Lungs: clear to auscultation*
• Cardiovascular: regular rhythm, tachycardia*
• Back: skin dimple and tuft of hair over the 5th lumbar vertebrae*
• Labs: Hgb = 6.8 gm/dL; Platelets = 89,000; Urine = 3+ protein)*

Answer 13

I would NOT extubate the child at the end of the procedure,

recognizing that mechanical ventilation would be required until the abdominal cavity had sufficiently expanded to accommodate the herniated viscera without severely compromising ventilation.