UBP 6.4 (Long Form): Obstetrics – Laparoscopic Appendectomy Flashcards
Secondary Subject -- Non-obstetric Surgery for the Obstetric Patient / Teratogenicity / Diabetic Stiff Joint Syndrome / Perioperative Steroid Administration / Tocolytic Therapy / DKA / Aspiration / Intra-operative Fetal Heart Rate Monitoring / Pneumoperitoneum for Laparoscopic Surgery / Fetal Heart Rate Variability / NSAIDs in Pregnancy / Post-operative Nausea and Vomiting / Electroconvulsive Therapy
Intra-operative Management:
What monitoring would you require for this case?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Given that this patient is pregnant, in DKA, and undergoing laparoscopic surgery,
this patient will require more extensive intraoperative monitoring.
Therefore, in addition to the ASA monitors, I would require:
- an arterial line for frequent blood draws (e.g., electrolytes, blood sugar), arterial blood gas analysis, and blood pressure management
- (DKA, 24 hours of nausea and vomiting, and possible diabetic autonomic neuropathy place her at risk for hemodynamic instability);
- a Foley catheter to follow urine output and decompress the bladder
- (to improve the surgeon’s view and reduce the risk of perforation during laparoscopy);
- transvaginal Doppler ultrasonography for continuous intraoperative fetal heart monitoring
- (allows for optimization of maternal hemodynamics when the FHR suggests fetal stress); and
- a tocodynamometer to identify uterine contractions preoperatively and postoperatively.
In addition to these monitors, I would place –
- an orogastric or nasogastric tube to empty and decompress the stomach
- (reduces the risk of pulmonary aspiration and surgical perforation during laparoscopy) and
- pneumatic compression devices on the lower limbs to reduce the risk of embolism
- (pregnant patients are hypercoagulable, and creation of the pneumoperitoneum promotes intraoperative venous stasis).
Intra-operative Management:
Is there any reason for continuous intraoperative fetal heart rate monitoring if the baby is not viable?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Yes.
Even though an emergent cesarean section is not an option for a nonviable baby (< 23 weeks),
intraoperative monitoring allows for optimization of maternal hemodynamics when the FHR suggests fetal stress.
While intraoperative monitoring is not always warranted,
this patient’s medical condition places her at increased risk for hemodynamic instability.
Should an unexplained change in FHR occur intraoperatively,
- I would quickly ensure adequate left uterine displacement, blood pressure, oxygenation, and volume replacement.
- I would then verify sinus rhythm;
- attempt to identify excessive bleeding or surgical impairment of uterine perfusion;
- check electrolytes, hemoglobin, and an ABG; and
- consider reducing the pneumoperitoneum
- (intra-abdominal pressures should optimally be maintained between 8-12 mmHg).
Intra-operative Management:
You are proceeding with general anesthesia.
Will you perform a RSI?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Assuming her airway exam was reassuring, she did not exhibit any signs of stiff joint syndrome, and her potassium was not too high (overaggressive potassium replacement in treatment of DKA can result in hyperkalemia, especially with the decreased urine output that often occurs during laparoscopy),
I would perform a rapid sequence induction using succinylcholine due to her increased risk of pulmonary aspiration secondary to the physiologic changes of pregnancy, potential diabetic autonomic neuropathy, appendicitis (delayed gastric emptying due to pain and inflammation), and nausea/vomiting.
However, I would likely use etomidate for my induction agent, recognizing that she is at increased risk for hemodynamic instability secondary to significant hypovolemia (DKA and 24 hours of nausea and vomiting) and possible autonomic neuropathy (diabetic neuropathy impairs peripheral vasoconstriction and baroreceptor function).
To further reduce her risk of aspiration, I would administer –
- metoclopramide, an H2-receptor antagonist, and/or a nonparticulate antacid;
- ensure the availability of difficult airway equipment
- (pregnancy independently increases the risk of difficult airway management, despite a reassuring airway exam);
- place the patient in slight reverse-trendelenburg;
- apply cricoid pressure during induction
- (I would be prepared to quickly release cricoid pressure if she began to vomit);
- insert an orogastric tube to empty the stomach following induction; and
- delay extubation until she was fully awake.
Intra-operative Management:
The patient is intubated and the surgery proceeds.
During creation of the pneumoperitoneum, her heart rate decreases to 46 bpm and her blood pressure begins to fall.
What will you do?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Since the timing of this event suggests a reflex increase in vagal tone with creation of the pneumoperitoneum, I would:
- ask the surgeon to discontinue insufflation;
- evaluate the ECG (the increased vagal tone can lead to cardiac arrhythmia),
- check her blood pressure;
- administer atropine (while glycopyrrolate is less likely to cross the placenta, the onset of action is too slow for acute treatment);
- ensure adequate oxygenation, ventilation, and left uterine displacement; and
- provide fluids and vasopressors as indicated.
However, recognizing that there are other potential causes of these hemodynamic changes (i.e. tension pneumothorax, metabolic and/or electrolyte disturbances, and significant CO2 embolism), I would also:
- verify proper endotracheal tube placement;
- auscultate the chest; and
- check the patient’s blood sugar, electrolytes, and arterial blood gases.
Following hemodynamic stabilization, I would ensure adequate intravascular volume and depth of anesthesia prior to allowing re-insufflation of the abdomen (preferably at a lower insufflation pressure).
Intra-operative Management:
Assume you placed a transvaginal Doppler to monitor fetal heart tones.
Now, you check the fetal heart rate tracing and note the absence of variability.
What do you think?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Fetal heart rate variability is important because it serves as a good indicator of fetal well-being.
However, the lack of variability is expected in this case, because fetal heart variability does NOT develop until the 25th to 27th week of gestation.
If the baby’s gestational age were more advanced and fetal heart rate variability was present preoperatively, it would be necessary –
- to distinguish the reduction in variability that occurs with the administration of atropine (since I used this in the treatment of the mother’s bradycardia) or induction of general anesthesia (especially when opioids are used) from that resulting secondary to fetal hypoxia.
In either case, the presence of severe and persistent bradycardia, tachycardia, or repetitive decelerations on the FHR tracing should prompt optimization of the mother’s hemodynamics and uteroplacental oxygen delivery (i.e. LUD, 100% oxygen, volume resuscitation, and blood pressure support).
Intra-operative Management:
The surgeon deflated the pneumoperitoneum at your request and the patient’s blood pressure stabilized.
Upon re-inflation the peak airway pressures increase and her oxygen saturation begins to drop. What will you do?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Recognizing that these findings are consistent with two complications associated with the creation of a pneumoperitoneum, –
- right mainstem intubation
- (cephalad displacement of the diaphragm and carina during pneumoperitoneum inflation can result in right mainstem intubation) and
- pneumothorax
- (e.g. capnothorax secondary to movement of CO2 into the thorax via congenital diaphragmatic defects or trauma-induced diaphragmatic communications,
I would:
- hand ventilate;
- switch to 100% oxygen;
- auscultate the lungs;
- verify proper endotracheal tube positioning (possibly using a fiberoptic bronchoscope); and
- check the ECG, blood pressure, and PetCO2 (increases with capnothorax and is usually unchanged with right stem intubation).
If the ETT were correctly positioned and the PetCO2 was elevated ( most likely capnothorax), I would – ask the surgeon to release the pneumoperitoneum and adjust her ventilation to facilitate the normalization of her CO2 levels.
Although a tension pneumothorax developing secondary to alveolar rupture (i.e. central line placement or rupture of an emphysematous bulla) may present with elevated airway pressures and decreased oxygen saturation, it is less likely to occur in this patient without pulmonary disease.
If this type of pneumothorax were suspected, and the patient were hemodynamically stable, I would:
- check the PetCO2 (often decreases with tension pneumothorax due to decreased cardiac output);
- order a bedside ultrasound (higher sensitivity than chest x-ray) or chest x-ray;
- examine the patient for hyper-resonance to percussion over the left thorax, contralateral tracheal shift, and distended neck veins (all associated with tension pneumothorax); and
- continue to monitor the patient closely for signs of developing hemodynamic instability.
If the patient became hemodynamically unstable before a definitive diagnosis could be made, I would have the surgeon place a chest tube.
Intra-operative Management:
The endotracheal tube was in the right mainstem bronchus, and the patient’s airway pressures return to normal after you correctly position it.
Would you proceed with the case using 100% oxygen?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Given this patient’s DKA and hemodynamic instability, I would proceed with 100% oxygen in order to optimize maternal and fetal oxygenation.
Using 100% oxygen instead of a mixture including N2O would have the additional advantage of avoiding an unfair association of a subsequent congenital abnormality with the use of nitrous oxide during the case
(the use of N2O could become a medico-legal issue despite the evidence that there is no increased risk of congenital abnormalities with intraoperative exposure to N2O).
Intra-operative Management:
Would you be worried about intrauterine retrolental fibroplasia or premature closure of the ductus arteriosus with the use of 100% oxygen?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Due to a large maternal-fetal oxygen tension gradient, fetal oxygen saturation never exceeds 50-60 mmHg, even with very high maternal oxygen saturation.
Therefore, increased maternal Pao2 does NOT increase the risk of intrauterine retrolental fibroplasia or premature closure of the ductus arteriosus.
However, despite this limited increase in fetal Pao2, the practice of providing 100% oxygen to the mother during times of fetal stress is justified because even small increases in fetal Pao2 may prove significant in improving fetal oxygenation due to the steep slope of the fetal oxyhemoglobin dissociation curve near the P50 of fetal blood (21 mmHg).
Post-operative Management:
The post-op nurse calls you because the patient is nauseous.
What are this patient’s risk factors for post-operative nausea and vomiting?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
This patient’s risk factors for post-operative nausea and vomiting include –
- female gender,
- laparoscopic surgery,
- pain (surgical pain and the inflammation from appendicitis),
- diabetic ketoacidosis, and the fact that she is a
- nonsmoker.
Other potential risks would include –
- anxiety,
- a prolonged surgical procedure,
- a history of motion sickness, and
- the intraoperative administration of volatile agents, nitrous oxide, opioids, and neostigmine.
Post-operative Management:
Tell me what steps could have been taken preoperatively and intraoperatively to reduce the risk of post-operative nausea and vomiting (PONV) for this patient at high risk?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Due to the multifactorial etiology of PONV, multimodal strategies have proven to be the most successful in reducing the incidence in high-risk patients.
Therefore, I could have provided adequate hydration, a scopolamine patch, and a benzodiazepine (should consider the medico-legal ramifications of giving a pregnant woman a benzodiazepine).
Moreover, the use of total intravenous anesthesia with propofol would have taken advantage of the antiemetic properties of propofol while avoiding the use of volatile agents and nitrous oxide (both of which may increase the incidence of PONV).
Finally, I could have asked the surgeon to inject local at the port sites to reduce post-operative narcotic requirements;
administered a serotonergic receptor antagonist (i.e. ondansetron) and/or a neurokinin-1 receptor antagonist (aprepitant) at wound closure; and applied acupressure at the P6 acupoint (inner aspect of the wrist).
While NSAIDs (reduce the need for opioid requirements), dexamethasone, and droperidol are often used to prevent or treat nausea, I would AVOID them in this particular case.
The administration of NSAIDs risks premature closure of the fetal ductus arteriosus, and should be used with caution in the second half of pregnancy (risk is greatest after 32 weeks gestation).
Droperidol, a dopamine receptor antagonist, is a category C drug and should only be given in pregnancy when the benefits outweigh the risks.
Finally, giving dexamethasone to this diabetic patient in DKA may further complicate plasma glucose control.
Post-operative Management:
The patient has been suffering from major depression and is scheduled to receive electroconvulsive therapy (ECT) next week.
Would you agree to this procedure?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
If pharmacotherapeutic agents were not an option (e.g. patient refusal, drug-resistant disorder, etc.) and the psychiatrist believed that treatment was necessary, then I would agree to proceed with ECT.
The decision to perform ECT during pregnancy is made in consultation with the patient’s psychiatrist and obstetrician, and involves weighing the risks of performing the procedure against the risks associated with an untreated psychiatric disorder (e.g. suicide, severe malnutrition/dehydration, catatonic state, etc.).
While performing ECT during pregnancy has been associated with vaginal bleeding, abdominal pain, uterine contractions, preterm labor, and neonatal cerebral infarction,
withholding treatment could lead to severe malnutrition/dehydration or even suicide.
Clinical Note:
- Conditions that have been listed as contraindications to ECT therapy include:
- intracranial mass lesions,
- vascular malformations,
- recent MI (< 3 months),
- recent stroke (< 1 month),
- increased ICP from any cause, and
- pheochromocytoma.
Post-operative Management:
The psychiatrist and obstetrician determine that ECT is necessary.
What are the physiologic effects of ECT?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
The parasympathetic discharge associated with the initial electrical stimulus results in – bradycardia, increased airway secretions, and hypotension
(the bradycardia usually lasts about 10-15 seconds, can be profound, and may progress to asystole).
Within 1 minute, generalized seizure actviity results in sympathetic activation, with subsequent tachycardia, hypertension, and possibly dysrhythmias
(the hypertension lasts for 2-10 minutes and may be significant, sometimes approaching 150% of baseline values).
The rapid increase in systemic blood pressure associated with this sympathetic activation results in increased cerebral blood flow (up to a seven-fold increase), intracranial pressure, and cerebral oxygen consumption.
Intraocular and intragastric pressures may also increase during the procedure (intraocular pressure may increase more than two-fold).
Post-operative Management:
How would you perform the anesthetic?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
In performing this anesthetic, I would:
- consult an obstetrician;
- verify the absence of contractions (tocodynamometry) and check the fetal heart rate immediately prior to the procedure;
- optimize her blood sugar;
- ensure adequate hydration
- (these patients are increased risk for hypotension due to parasympathetically-induced bradycardia and poor oral intake secondary to depression or psychosis);
- provide aspiration prophylaxis
- (increased risk for aspiration secondary to pregnancy and the increase in intragastric pressure associated with ECT);
- administer glycopyrrolate (0.2 mg) 1-2 minutes prior to induction to reduce airway secretions and attenuate the bradycardia that often occurs within the first few seconds of electrical stimulation
- (glycopyrrolate is less likely to cross the placenta than atropine);
- ensure left uterine displacement
- (required after 18 weeks gestation);
- perform a rapid sequence induction with succinylcholine, etomidate, and cricoid pressure
- (Etomidate produces a longer seizure duration, but may result in myoclonus, more severe postictal hypertension, and delayed recovery.
- Other options include methohexital and propofol.);
- place an ETT;
- insert a bite guard;
- moderately hyperventilate the patient to enhance the quality and duration of seizures; and
- administer labetalol with the initiation of generalized seizure to attenuate the hypertension and tachycardia that often occurs secondary to seizure-induced activation of the sympathetic system
- (although esmolol may have a lesser effect on seizure duration, its use in pregnancy is controversial secondary to an association with fetal bradycardia and maternal hypotension).
- Following the procedure, I would – extubate the patient when fully awake and – monitor the patient postoperatively for uterine contractions, decreased fetal heart rate, and vaginal bleeding.
Post-operative Management:
Would you perform a rapid sequence induction?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Although this procedure is often performed with mask ventilation,
I would perform a rapid sequence induction in this case due to –
- her increased risk for aspiration secondary to the increases in intragastric pressure that occur with ECT,
- her diabetes (potential diabetic autonomic neuropathy), and
- the physiologic changes associated with pregnancy, such as –
- progesterone-induced reductions in lower esophageal sphincter tone,
- increased intragastric pressure (secondary to increasing uterine size),
- delayed gastric emptying, and
- the mechanical effects of the gravid uterus on the gastro-esophageal junction.
However, since initial ECT therapy often occurs three times per week (as opposed to maintenance therapy, which would occur less frequently), I recognize that repeated intubations place her at increased risk for airway trauma and/or edema.
Therefore, I would make every effort to place the ETT as atraumatically as possible.
Post-operative Management:
Is muscle relaxation necessary?
- (A 16-year-old, 5’4”, 68 kg, pregnant female presents for laparoscopic appendectomy at 22 weeks gestation.*
- HPI: The patient has had gradually increasing right lower quadrant pain for the past 3 days. She also reports a loss of appetite and vomiting. This morning the pain became so intense that she went to the ER. Preoperatively, it was discovered that she is in DKA and treatment was initiated 3 hours ago.*
- PSH: She has not had any previous surgery. Her parents state there are no known family problems with anesthesia.*
- Meds: 20 U of NPH, 10 U of Lispro insulin,*
- Zoloft – has not been taking during pregnancy*
- PMH: The patient is 22 weeks pregnant and a poorly controlled insulin dependent diabetic. She takes 20 U of NPH and 10 U of Lispro insulin each morning. She has also suffered from depression for several years.*
- PE: Vital Signs: BP = 128/86 mmHg, P = 93, R = 18, T = 37.8 C*
- Airway: Mallampati score of II*
- Abdominal: The patient exhibits abdominal tenderness and guarding*
- Lab: H/H = 11.5/34; Na+ = 138 mEq/L; platelets = 122,000; serum glucose = 240 mg/dL; urine = elevated ketones;*
- ABG: pH 7.25; Paco2 29; Pao2 94; HCO3 15; Spo2 = 98% on room air)*
Muscle relaxation is usually employed to reduce the risk of bone fractures and joint dislocations that may occur secondary to seizure-induced skeletal muscle contractions.
Small doses of succinycholine (0.25 mg/kg) are usually sufficient to attenuate these muscle contractions, while still allowing for the visual confirmation of seizure activity.
When larger doses of succinylcholine (0.75-1.5 mg/kg) or nondepolarizers are utilized, seizure activity may be confirmed by EEG or the application of a tourniquet to an extremity prior to the administration of the muscle relaxant (allows for the visualization of tonic/clonic activity in the extremity).
