UBP 6.1 (Long Form): Obstetrics – Preeclampsia/Eclampsia Flashcards
Secondary Subject -- HELLP / Magnesium Toxicity / Difficult Airway / Neuraxial Blockade in the Coagulopathic Patient / Emergency Cesarean Section / Failed Neuraxial Anesthesia / Neonatal Resuscitation / Intravenous and Intraosseous access in the newborn / Maternal Hemorrhage / Uterine Atony / Seizure Management / Pulmonary Edema / ABG Interpretation
Intra-operative Management:
Would you provide general or regional anesthesia?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
Regional anesthesia would be my first choice because the usual changes associated with pregnancy
(i.e. airway edema, decreased functional residual capacity, increased oxygen consumption, decreased lower esophageal sphincter tone, weight gain, and enlarged breasts),
the airway edema often associated with preeclampsia, her receding jaw, and a Mallampati Class III airway would all potentially complicate intubation and/or mask ventilation.
My choice of anesthetic would, however, be dependent upon the time constraints of performing the C/S, the complete airway exam, coagulation status, volume status, and any other contributing factors.
Intra-operative Management:
As you consider regional anesthesia, are you concerned about her coagulation status?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
I am concerned about her coagulation status.
While pregnant women tend to be hypercoagulable, preeclampsia can reduce platelet number and impair platelet function, increasing the risk for epidural or spinal hematoma.
In making a decision to provide regional anesthesia in this case, I would consider the trend of the platelet number in addition to the absolute number.
I would also perform a history and physical exam focusing on the airway and signs of coagulopathy such as bleeding at the IV site, mucosal bleeding, and marked or easy bruising.
Intra-operative Management:
You have dosed the epidural with local anesthetic. However, when the surgeon makes the incision, the patient complains of significant pain. What will you do?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
Depending on the status of the baby, urgency of the c-section, and the location and severity of the pain,
I would consider re-dosing, repositioning, or replacing the catheter; local infiltraion with/without sedation; or general anesthesia.
If time allowed, I would attempt to improve the function of the epidural in order to avoid:
- replacing a catheter in a preeclamptic patient with potential coagulopathy (there is an additional risk of vascular trauma during replacement);
- providing sedation to a pregnant patient with a potentially difficult airway and increased risk of aspiration; or
- inducing general anesthesia for a patient with an increased risk of difficult airway management and aspiration.
Intra-operative Management:
Everything has been tried and the epidural will not work. The baby’s heart tones are down and the OB says, “We have to cut now!” What will you do?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
Speed and safety are my main goals here.
The first step would be to optimize the mother’s hemodynamics by ensuring adequate uterine displacement and addressing any hypotension, hypertension, hypoxia (apply 100% oxygen), and/or rapid or irregular heart rate that might compromise utero-placental perfusion.
This may improve her baby’s condition and buy time to achieve adequate analgesia.
If these interventions were unsuccessful, and local infiltration combined with a small dose of ketamine were insufficient to control her discomfort (given her potentially difficult airway, any sedation should be administered with the goal of maintaining spontaneous respirations),
the most conservative option would be to delay surgery until I could safely secure the airway by performing an awake fiberoptic intubation (increased risk for the baby due to the associated delay of delivery, but the mother is the primary patient).
However, recognizing that delaying surgery for an awake fiberoptic intubation places the baby at significant risk, I could also consider inducing general anesthesia without first securing the airway.
In this case, I would:
- ensure the presence of difficult airway equipment,
- prepare for a possible cricothyrotomy or tracheostomy,
- preoxygenate with 100% oxygen via a tight fitting mask,
- apply cricoid pressure,
- place the patient in slight reverse-trendelenburg (improved respiratory mechanics and intubating conditions along with reduced risk of passive aspiration),
- perform an inhalational induction, with the goal of maintaining spontaneous respiration, and
- attempt to intubate the patient.
If intubation were unsuccessful after one attempt, I would continue to deliver volatile agent through the mask and allow the obstetric team to deliver the baby.
Following delivery of the baby, I would ask the surgical team to delay closure until I definitively secured the airway (i.e. fiberoptic bronchoscope, video laryngoscope, intubating LMA, etc.).
Intra-operative Management:
Despite some difficulty, you manage to intubate the patient; her blood pressure increases to 208/104 mmHg. What will you do?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
First, I would check another blood pressure and, at the same time, verify proper ETT placement.
I would then check my monitors and ventilation settings, and look for signs of light anesthesia such as tearing, sweating, and movement.
If I thought light anesthesia were the cause rather than hypoxia, hypercarbia, increased ICP (she is preeclamptic), drug error, or artifact, I would administer a bolus of propofol and titrate on a higher concentration of inhalational agent.
If the high blood pressure persisted, I would consider administering labetalol or even sodium nitroprusside if necessary.
Clinical Note:
- It would be important to rule out elevated intracranial hypertension efore treating her blood pressure aggressively. In the setting of intracranial hypertension, it would be more appropriate to begin with measures to reduce intracranial hypertension.
Intra-operative Management:
After delivery, baby B is not crying and remains apneic. The mother is stable. You are asked to help with neonatal resuscitation. What will you do?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
As long as the mother was stable and if no one else was immediately available to resuscitate the baby, I would have someone call for help and have the nurse push the baby’s crib to the head of the operating table where I could assist in resuscitation while at the same time monitoring the mother’s condition.
In this situation, I would keep in in mind that the mother is my primary responsibility and then weigh the risk of taking any actions that may distract me from her care against the consequences of not aiding in the neonate’s resuscitation.
Intra-operative Management:
What steps would you take in resuscitating the neonate?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
I would rapidly asses the neonate (gestational age, ventilation, muscle tone);
clear the airway; and warm, dry, and stimulate the baby.
If following these initial steps the baby’s heart rate was below 100, he remained apneic, or he was gasping, I would –
- provide positive mask ventilation with air or an air/oxygen mixture and
- consider applying a pulse oximeter.
If after 30 seconds the HR was less than 60, then – I would –
- intubate,
- increase the oxygen concentration to 100%,
- begin chest compressions (3 compressions to 1 breath for a total of 120 events/minute), and
- establish venous (umbilical vein catheterization) or intraosseous access (risks include tibial fracture and osteomyelitis).
If after another 30 seconds there were still no improvement, I would –
- administer 0.01-0.03 mg/kg of epinephrine via the umbilical vein or established intraosseous access, and
- consider volume expansion.
Given the mother’s diabetes and the recent administration of magnesium sulfate, I would also consider hypoglycemia and magnesium toxicity.
Intra-operative Management:
Would you administer Calcium?
(to the newborn needing resuscitation… see previous question)
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
Since calcium administration may lead to cerebral calcification and decreased survival in stressed newborns, I would only administer this drug to treat known magnesium toxicity.
However, recognizing the potential for magnesium toxicity in this case (preeclamptic mother receiving magnesium sulfate), I would check the neonate’s magnesium level and treat accordingly.
If magnesium toxicity were confirmed, I would administer calcium (100 mg/kg of calcium gluconate or 30 mg/kg of CaCl2).
Intra-operative Management:
When and where would you consider placing a pulse oximeter?
(to the newborn needing resuscitation… see previous question)
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
I would consider utilizing oximetry –
- when I anticipated the need for resuscitation,
- when positive pressure ventilation was required for more than a few breaths,
- when supplemental oxygen was necessary, or
- when cyanosis was persistent.
I would place the oximeter on the right upper extremity (finger, wrist, or medial palmar surface) in order to monitor pre-ductal blood flow, which provides a better assessment of central nervous system oxygenation.
Unfortunately, it often takes 1-2 minutes to place and obtain reliable readings from the pulse oximeter.
Intra-operative Management:
When would you consider intubating the neonate?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
I would consider endotracheal intubation during neonatal resuscitation when:
- a non-vigorous meconium-stained neonate required initial endotracheal suctioning;
- bag mask ventilation was ineffective;
- chest compressions became necessary;
- prolonged mechanical ventilation was anticipated;
- endotracheal administration of drugs was desired (intravenous or intraosseous administration is preferred); and
- when required for special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight (<1000 g).
I would then utilize exhaled CO2 detection to confirm endotracheal tube placement, recognizing that inadequate pulmonary blood flow may lead to a false-negative result with subsequent unnecessary extubation and re-intubation.
Intra-operative Management:
The neonatal HR is less than 60 and you decide to give epinephrine. Unfortunately, you have been unable to establish intravenous access. What would you do?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
If I was unable to obtain intravenous access in a timely manner,
I would attempt to acquire intraosseous access by inserting a 20-gauge needle into the proximal tibia at a caudal angulation (about 1 cm below the tibial tuberosity), recognizing that this procedure risks tibial fracture and osteomyelitis (the line should be removed in 1-2 hours to reduce the risk of the latter complication).
If I were similarly unable to establish intraosseous access in a timely manner, I would consider administering epinephrine through the endotracheal tube.
Since there is some evidence that the normal IV dose of 0.01-0.03 mg/kg is ineffective when administered through the endotracheal tube, I would consider administering a higher dose up to 0.1 mg/kg diluted in 1-2 cc of normal saline, recognizing that the safety and efficacy of administering epinephrine through an ETT is not clearly established.
Intra-operative Management:
You have successfully resuscitated the baby.
Maternal bleeding, however, continues despite the administration of oxytocin. What will you do?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
I would make sure the patient is stable, ensure adequate IV access, and give fluids, blood, and vasoactive agents as necessary.
I would also communicate with the surgeon and observe the surgical field (including the uterus, if externalized) looking for an obvious cause of continued bleeding.
Given the uterine distension that occurs with a twin pregnancy, the most likely cause of continued bleeding in this case is uterine atony.
Other causes may include –
- retained placental parts,
- uterine rupture,
- placental accreta, or
- coagulopathy.
If it appeared that uterine atony was the cause of continued bleeding, I would consider –
- reducing my inhalational agent,
- increasing the dose of oxytocin, and/or
- administering 15-methyl-prostaglandin F2-alpha (Hemabate).
- If these interventions did not resolve the problem, I would consider administering misoprostol (Cytotec; a prostaglandin E1 analogue; 800-1000 mcg per rectum) or dinoprostone (prostaglandin E2; 20 mg vaginal or rectal administration).
Given the potential for exacerbation of hypertension following methylergonovine (Methergine) administration, I would probably avoid giving this medication to this patient with pregnancy-induced hypertension.
Moreover, depending on severity of the bleeding, I may employ a rapid infusing device or a cell-saver.
If all of these measures were unsuccessful, the surgeon may have to employ an intrauterine balloon (works via tamponade; success rate up to 80%); place uterine compression sutures; ligate the internal iliac, uterine, and ovarian arteries; and/or perform an emergency hysterectomy.
Intra-operative Management:
How do oxytocin, Methergine, and Hemabate work?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
Oxytocin, Methergine, and Hemabate cause contraction of myometrial smooth muscle by increasing intracellular calcium levels.
It is important to remember that Hemabate is associated with bronchospasm and should probably be avoided in asthmatic patients when possible.
Methergine is associated with hypertension, especially when administered intravenously, and should be given intramuscularly except in the case of life threatening hemorrhage.
Oxytocin can cause hypotension when given as an intravenous bolus and should be administered in a dilute solution (20 units in 1 liter of fluid).
Post-operative Management:
After extubation, the mother is transferred to the PACU and, while there, suddenly develops a seizure. What do you think is going on, and how will you treat her?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
This is most likely an eclamptic seizure resulting from the physiologic changes that occur with preeclampsia.
However, hypoxia, hypotension (hypovolemia, residual anesthetic, etc.), intracranial hemorrhage (secondary to preeclampsia and/or the significant intra-operative hypertension following intubation), hypoglycemia (diabetic and taking insulin), and local anesthetic toxicity (large amounts of local anesthetic most likely administered when attempting to achieve adequate epidural anesthesia) should be considered.
Given that securing the airway at the beginning of the case was somewhat difficult, I would:
- provide 100% oxygen,
- administer 3-5 cc’s of propofol (or a small dose of a benzodiazepine),
- have someone get the difficult airway cart and
- call a surgeon capable of performing a tracheostomy.
- I would then position the patient in reverse trendelenburg (to reduce the risk of passive regurgitation and to facilitate intubation),
- apply cricoid pressure, and
- perform laryngoscopy with the goal of maintaining spontaneous respirations. However, I would recognize that utilizing such a small dose of propofol for intubation places this patient with a full stomach and eclampsia at increased risk for aspiration, hypertension, and cerebral hemorrhage (due to light anesthesia). Finally, after the ETT was secured, I would consider
- administering midazolam for its anti-seizure and amnestic effects.
Post-operative Management:
If she were breathing spontaneously, would you attempt to intubate her when you had difficulty doing so at induction?
- (26-year-old, 5’6” tall, 280 lb, G1P0 female in preterm labor with breech twins is going to the operating room for cesarean section.*
- HPI: Preeclampsia and gestational diabetes*
- Anesthesia Hx: None. Parents have not had any problems with anesthesia.*
- Medications: MgSo4, regular insulin.*
- PMH: Unremarkable.*
- PE: VS: HR = 94; R = 18; BP = 168/97; T = 37 C*
- CV: RRR / Lungs: CTAB / Abd: RUQ tenderness / General: Awake and alert /*
- Airway: MP III, small receding jaw*
- Labs: Hgb 12; Platelets 90,000; PT 12; PTT 44 (elevated); INR 1.1; Na 132; K 3.4; blood sugar 150; proteinuria (5400 mg collected over 24 hours)*
- Liver enzymes: normal*
- Peripheral blood smear: no hemolysis*
- CXR = no apparent disease*
- EKG = normal sinus rhythm)*
Yes. I think that it is important to secure her airway because her mental status, which may already be diminished, could deteriorate further with worsening cerebral pathology, placing her at progressively increasing risk of aspiration, hypoventilation, and apnea.
The fact that intubation and/or ventilation may prove difficult makes securing her airway now, while she is spontaneously breathing, even more important.
Her current ability to breathe spontaneously allows me more time to safely secure her potentially difficult airway.
A “wait and see” strategy could place me in the position of having to emergently secure her airway with little time for preparation and intubation.
