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Apnoeic oxygenation during maternal cardiac arrest in a parturient with extreme obesity
International Journal of Obstetric Anesthesia (2016) xxx, xxx–xxx 0959-289X/$ - see front matter Ó 2016 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2016.11.003
CORRESPONDENCE Apnoeic oxygenation during maternal cardiac arrest in a parturient with extreme obesity Dear Editor, We would like to describe the first reported successful use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) via OptiflowTM high-flow nasal cannulae (Fisher and Paykel Healthcare, Auckland, New Zealand) in a class III obesity (World Health Organisation) parturient who suffered an intraoperative cardiac arrest during an elective caesarean delivery (CD). A 40-year-old gravida 4, para 3 woman weighing 153 kg (body mass index (BMI) 60 kg/m2) presented for an elective CD at 36+6 week’s gestation. Previously she had two vaginal deliveries followed by an emergency CD. Her past medical history included benign intracranial hypertension, asthma and gestational diabetes, treated with insulin and metformin, in the current pregnancy. Her airway assessment included a large neck circumference and Mallampati 3 view. A combined spinal-epidural anaesthetic (2.3 mL 0.5% heavy bupivacaine and 300 mcg diamorphine) was performed and the patient positioned for surgery using an Oxford HelpÒ pillow (Alma Medical, London, UK) with left lateral tilt. A THRIVE device with OptiflowTM was applied at a flow rate of 30 L/min and inspired oxygen fraction (Fi02) of 1.0. Oxygen saturation (SpO2) was maintained at 99–100%. Despite clear fluid returning from the spinal needle hub, no discernible block was produced. After 15 minutes, a total of 20 mL 2% lidocaine with 1 in 200 000 epinephrine and clonidine 75 mcg were administered epidurally, producing a bilateral block to temperature at T4, light touch at T5 and a lower limb motor block of Bromage score 4. A variable rate phenylephrine infusion was started at 0.8 mcg/kg/ min but only small doses were required (0.1 mcg/kg/ min). Her baseline heart rate (HR) was 80 beats/min and blood pressure (BP) 140/70 mmHg. Due to the patient’s body habitus, entering the abdominal cavity was surgically difficult. An hour into the operation, at which time the uterus had still not been incised, the patient described feeling unwell, experiencing dizziness and nausea. Her non-invasive BP at this time was 120/74 mmHg (one minute cycling) but her HR fell from 80 to 30 beats/min and within seconds, despite the surgery being suspended, asytole occurred. Chest compressions were commenced and glycopyrrolate 600 mcg and epinephrine 1 mg were administered.
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The THRIVE system flow rate was increased to 60 L/ min. Airway patency was maintained using jaw thrust and a facemask, attached to the circle circuit on the anaesthetic machine, was applied with an oxygen flow rate of 15 L/min, while equipment was prepared for intubation. After 60 seconds of chest compressions, the patient displayed signs of life (eye opening), the first BP recording after return of spontaneous circulation being 200/90 mmHg and SpO2 99%. An arterial line was sited and surgery continued. A post resuscitation arterial blood gas showed a PaO2 of 11.2 kPa and blood glucose 7.3 mmol/L. The patient regained full consciousness within minutes of the asystolic episode. Twenty minutes later, a live 4.1 kg female infant, with Apgar scores of 8 and 10 at 1 and 5 minutes respectively, was delivered. In the neonatal unit she required intubation to deliver surfactant to treat respiratory distress, thought to be secondary to poor maternal blood sugar control during pregnancy. During the operation, the patient experienced a further three episodes of dizziness associated with hypotension (lowest 80/50 mmHg), however her HR remained between 70–80 bpm. These episodes corresponded with increased surgical pressure on the abdominal peritoneum and resolved when surgical stimulation ceased. The likely cause for the asystolic cardiac arrest and these episodes was considered to be intense vagal stimulation. The patient was observed in the intensive care unit for three days, an echocardiogram showing preserved left ventricular function and no other abnormalities. The baby was discharged on day 6 after birth. Two weeks after delivery the patient was re-admitted with a suspected deep vein thrombosis, which was subsequently excluded, but low molecular weight heparin therapy was continued for 6 weeks. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange is provided during apnoea by high flow humidified oxygenation devices.1 Oxygenation is maintained via mass flow and continuous positive airway pressure (CPAP) with continuous insufflation. Approximately 7 cmH2O of CPAP is achieved and a degree of carbon dioxide clearance results from the shift of dead space gas.2 Transnasal high flow humidified oxygenation devices are increasing in popularity within anaesthesia1,3 and our institution uses THRIVE for pre-oxygenation of patients with anticipated difficult airways during induction of anaesthesia, awake fibreoptic intubation and procedures requiring sedation. It is also used as an alternative to CPAP administered via tight fitting facemasks within the intensive care unit. Intubation and bag mask ventilation was predicted to be difficult in this patient and she was at risk of the rapid
2 onset of hypoxaemia when apnoeic, for example during cardiac or respiratory arrest. Large studies demonstrating the benefit and safety of THRIVE within the obstetric population are currently lacking. However apnoeic oxygenation without desaturation has been described for up to 65 minutes using THRIVE in the non-pregnant population.1 Computer-simulation models of pregnant respiratory physiology suggest nasal oxygen (FiO2 1.0) can increase the time before oxygen desaturation to 40% from four and a half to 58 minutes.4 Both European Resuscitation Council and American Heart Association guidelines mention passive oxygen delivery, but do not recommend its routine use during cardiopulmonary resuscitation until more clinical data become available.5,6 This is the first report of THRIVE to aid oxygenation during maternal cardiac arrest or during cardiac arrest in an obese patient. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange may have mitigated the requirement for intubation in this patient, by providing apnoeic oxygenation during her brief cardiac arrest. We believe THRIVE is a well-tolerated intervention that should be considered for elective CD in the obese parturient.
International Journal of Obstetric Anesthesia S. Phillips , S. Subair, T. Husain, P. Sultan University College Hospital London, United Kingdom Correspondence address: Department of Anaesthesia Maple-link Corridor, Level 3 University College Hospital London 235 Euston Road London NW1 2BU United Kingdom. E-mail address: [email protected]
References 1. Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with a difficult airway. Anaesthesia 2015;70:323–9. 2. Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care 2011;39:1103–10. 3. Badiger S, John M, Fearnley RA, Ahmed I. Optimising oxygenation and intubation conditions during awake fibre-optic intubation using a high flow nasal oxygen delivery system. Br J Anaesth 2015;115:629–32. 4. Pillai A, Chikhani M, Hardman JG. Apnoeic oxygenation in pregnancy: a modeling investigation. Anaesthesia 2016;71: 1077–80. 5. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 3. Adult advanced life support. Resuscitation 2015;95:100–47. 6. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Care. Circulation 2015;132:S414–35.
CORRESPONDENCE Apnoeic oxygenation during maternal cardiac arrest in a parturient with extreme obesity Dear Editor, We would like to describe the first reported successful use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) via OptiflowTM high-flow nasal cannulae (Fisher and Paykel Healthcare, Auckland, New Zealand) in a class III obesity (World Health Organisation) parturient who suffered an intraoperative cardiac arrest during an elective caesarean delivery (CD). A 40-year-old gravida 4, para 3 woman weighing 153 kg (body mass index (BMI) 60 kg/m2) presented for an elective CD at 36+6 week’s gestation. Previously she had two vaginal deliveries followed by an emergency CD. Her past medical history included benign intracranial hypertension, asthma and gestational diabetes, treated with insulin and metformin, in the current pregnancy. Her airway assessment included a large neck circumference and Mallampati 3 view. A combined spinal-epidural anaesthetic (2.3 mL 0.5% heavy bupivacaine and 300 mcg diamorphine) was performed and the patient positioned for surgery using an Oxford HelpÒ pillow (Alma Medical, London, UK) with left lateral tilt. A THRIVE device with OptiflowTM was applied at a flow rate of 30 L/min and inspired oxygen fraction (Fi02) of 1.0. Oxygen saturation (SpO2) was maintained at 99–100%. Despite clear fluid returning from the spinal needle hub, no discernible block was produced. After 15 minutes, a total of 20 mL 2% lidocaine with 1 in 200 000 epinephrine and clonidine 75 mcg were administered epidurally, producing a bilateral block to temperature at T4, light touch at T5 and a lower limb motor block of Bromage score 4. A variable rate phenylephrine infusion was started at 0.8 mcg/kg/ min but only small doses were required (0.1 mcg/kg/ min). Her baseline heart rate (HR) was 80 beats/min and blood pressure (BP) 140/70 mmHg. Due to the patient’s body habitus, entering the abdominal cavity was surgically difficult. An hour into the operation, at which time the uterus had still not been incised, the patient described feeling unwell, experiencing dizziness and nausea. Her non-invasive BP at this time was 120/74 mmHg (one minute cycling) but her HR fell from 80 to 30 beats/min and within seconds, despite the surgery being suspended, asytole occurred. Chest compressions were commenced and glycopyrrolate 600 mcg and epinephrine 1 mg were administered.
www.obstetanesthesia.com
The THRIVE system flow rate was increased to 60 L/ min. Airway patency was maintained using jaw thrust and a facemask, attached to the circle circuit on the anaesthetic machine, was applied with an oxygen flow rate of 15 L/min, while equipment was prepared for intubation. After 60 seconds of chest compressions, the patient displayed signs of life (eye opening), the first BP recording after return of spontaneous circulation being 200/90 mmHg and SpO2 99%. An arterial line was sited and surgery continued. A post resuscitation arterial blood gas showed a PaO2 of 11.2 kPa and blood glucose 7.3 mmol/L. The patient regained full consciousness within minutes of the asystolic episode. Twenty minutes later, a live 4.1 kg female infant, with Apgar scores of 8 and 10 at 1 and 5 minutes respectively, was delivered. In the neonatal unit she required intubation to deliver surfactant to treat respiratory distress, thought to be secondary to poor maternal blood sugar control during pregnancy. During the operation, the patient experienced a further three episodes of dizziness associated with hypotension (lowest 80/50 mmHg), however her HR remained between 70–80 bpm. These episodes corresponded with increased surgical pressure on the abdominal peritoneum and resolved when surgical stimulation ceased. The likely cause for the asystolic cardiac arrest and these episodes was considered to be intense vagal stimulation. The patient was observed in the intensive care unit for three days, an echocardiogram showing preserved left ventricular function and no other abnormalities. The baby was discharged on day 6 after birth. Two weeks after delivery the patient was re-admitted with a suspected deep vein thrombosis, which was subsequently excluded, but low molecular weight heparin therapy was continued for 6 weeks. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange is provided during apnoea by high flow humidified oxygenation devices.1 Oxygenation is maintained via mass flow and continuous positive airway pressure (CPAP) with continuous insufflation. Approximately 7 cmH2O of CPAP is achieved and a degree of carbon dioxide clearance results from the shift of dead space gas.2 Transnasal high flow humidified oxygenation devices are increasing in popularity within anaesthesia1,3 and our institution uses THRIVE for pre-oxygenation of patients with anticipated difficult airways during induction of anaesthesia, awake fibreoptic intubation and procedures requiring sedation. It is also used as an alternative to CPAP administered via tight fitting facemasks within the intensive care unit. Intubation and bag mask ventilation was predicted to be difficult in this patient and she was at risk of the rapid
2 onset of hypoxaemia when apnoeic, for example during cardiac or respiratory arrest. Large studies demonstrating the benefit and safety of THRIVE within the obstetric population are currently lacking. However apnoeic oxygenation without desaturation has been described for up to 65 minutes using THRIVE in the non-pregnant population.1 Computer-simulation models of pregnant respiratory physiology suggest nasal oxygen (FiO2 1.0) can increase the time before oxygen desaturation to 40% from four and a half to 58 minutes.4 Both European Resuscitation Council and American Heart Association guidelines mention passive oxygen delivery, but do not recommend its routine use during cardiopulmonary resuscitation until more clinical data become available.5,6 This is the first report of THRIVE to aid oxygenation during maternal cardiac arrest or during cardiac arrest in an obese patient. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange may have mitigated the requirement for intubation in this patient, by providing apnoeic oxygenation during her brief cardiac arrest. We believe THRIVE is a well-tolerated intervention that should be considered for elective CD in the obese parturient.
International Journal of Obstetric Anesthesia S. Phillips , S. Subair, T. Husain, P. Sultan University College Hospital London, United Kingdom Correspondence address: Department of Anaesthesia Maple-link Corridor, Level 3 University College Hospital London 235 Euston Road London NW1 2BU United Kingdom. E-mail address: [email protected]
References 1. Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with a difficult airway. Anaesthesia 2015;70:323–9. 2. Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care 2011;39:1103–10. 3. Badiger S, John M, Fearnley RA, Ahmed I. Optimising oxygenation and intubation conditions during awake fibre-optic intubation using a high flow nasal oxygen delivery system. Br J Anaesth 2015;115:629–32. 4. Pillai A, Chikhani M, Hardman JG. Apnoeic oxygenation in pregnancy: a modeling investigation. Anaesthesia 2016;71: 1077–80. 5. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015 Section 3. Adult advanced life support. Resuscitation 2015;95:100–47. 6. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Care. Circulation 2015;132:S414–35.