MEDICAL EMERGENCIES (2) - Free State Department of Health

Report
MEDICAL EMERGENCIES
(2)
Dr. Gillian Lamacraft
Anaesthetic Specialist
University of the Free State
Agenda
Pre-eclampsia/Eclampsia
 Coagulopathy
 Fetal Distress
 Video on cricothyrotomy
 Failed intubation
 Video on MH

Anaesthesia and Pre-eclampsia
Emergency delivery at level 1 :
 fetal distress, placental
abruption
 Spinal or General Anaesthetic

Anaesthetic Considerations in
PE
Urgency of situation
 Fluid balance
 BP control (Mg?)
 Difficult intubation
 Complicated PE


eg coagulopathy ?
Fluid balance and PE





Pathology – vasospasm, leaky
capillaries  intravascular fluid deficit.
Crystalloids vs colloids
Renal failure vs pulmonary oedema.
Fetal distress and dehydration.
Post-delivery reduction in colloid
oncotic pressure.
Fluids and PE

Hospital protocol





usual maintenance 1ml/kg/hr crystalloid.
oliguria(<0.5ml/kg/hr)  2ml/kg fluid
challenge.
Monitor fluid balance
Peripheral route for CVP line
Beware CVP >6cmH2O
Spinal Anaesthesia and PE
Safer than GA
 BUT must be well hydrated
 Platelets >100x109/l
 Caution with fluids
 Preload 300-500ml colloid
 Judicious use of vasopressors

General Anaesthesia and PE



Difficult intubation
 *equipment and ET tubes
Blood pressure controlled preinduction
++Pressor response to intubation
 CVA
 Pulmonary oedema
Reducing the Intubation
Response
MgSO4 30mg/kg + alfentanil
7.5g/kg
 4g Mg in 200ml N Saline over
20minutes
 Fentanyl 2-3g/kg
 Delivery within 10 minutes
 Labetalol 5 – 10mg

Reducing the Extubation
Response
Lignocaine up to 1.5mg/kg
 Esmolol 1.5mg/kg

Neuromuscular Blockade and
Magnesium




Prolongs action of SUX.
Reduces SUX fasciculations.
Potentiates non-depolarising drugs.
Intermittent boluses of SUX +atropine

100mg SUX + 0.5mg atropine made up to 10ml in
water: 1-2ml boluses.
Eclampsia and Anaesthesia
Seizure: magnesium 4g IV over 510 minutes then maintenance.
 Most patients drowsy/irritable
GA.
 Spinal can be used if no
contraindications.

Coagulopathy

Associated with PE
 Isolated thrombocytopenia
 HELLP
 DIC
HELLP SYNDROME
Haemolytic anaemia
 Elevated Liver enzymes
 Low Platelets
 Severe variant of PE

(HELLP)
 High
maternal and perinatal
mortality
 May not have BP or proteinuria
 Older, multiparous
 Epigastric pain, nausea +
vomiting
HELLP and Anaesthesia
As for PE + coagulopathy
 Rate of platelet decline
 Blood components
 Post-op ICU



Renal failure (7.4%)
Deterioration in coagulopathy
DIC
(Disseminated Intravascular
Coagulopathy)


Procoagulant 
 IV fibrin
 Depletion clotting factors and platelets
Activation fibrinolytic system 
 Fibrin degradation products
 anticoagulant
Obstetric Triggers For DIC



Tissue thromboplastin
 Placental abruption
 Amniotic fluid embolism
Endothelial damage
 HELLP
Hypotensive conditions
 G-ve sepsis, massive haemorrhage
Tests for DIC
Prolonged APTT, PT, thrombin
times
  fibrinogen and anithrombin III
  platelets
  fibrin degradation products, D
dimers

DIC Treatment
Remove cause
 Supportive
 Bleeding:




FFP
cryoprecipitate
Platelets
Fetal Distress
Inadequate oxygen delivery
 Tachycardia then bradycardia

Treat reversible causes, eg:
 Maternal
hypoxia
 Hypotension
 Prolonged uterine contraction
(TNT 50-100g)
 Umbilical cord compression
Categories of Emergency CS
URGENCY
(time to delivery)
Stable (2 hours)
Spinal or GA?
EXAMPLE
spinal
Previous CS in
labour
Urgent (1hour)
spinal
Failure to progress
Emergency (30mins)
One attempt
spinal/GA
Severe FH rate
abnormality
Immediate
GA
Ruptured uterus
Video on Cricothyrotomy

Consider early in Obstetric Failed
Intubation Scenario
PROTOCOL FOR FAILED INTUBATION
Video of Malignant
Hyperthermia
Rare but treatable cause of
anaesthetic-related death.
 Ca release in sarcoplasmic
reticulum
 Stimulates muscular contraction
 Treatment: dantrolene

ANY QUESTIONS?
TELEPHONE: 051 405 3307
(Dept Anaesthesia)
 E-mail: [email protected]

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