- Email: [email protected]
Cardiac arrest during caesarean section for twins
196
References 1. Torrillo T M, Bronster D J, Beilin Y. Delayed diagnosis of posterior reversible encephalopathy syndrome (PRES) in a parturient with preeclampsia after inadvertent dural puncture. Int J Obstet Anesth 2007; 16: 171–4. 2. Prout P E, Tuckey J P, Giffen N J. Reversible posterior encephalopathy syndrome in a peripartum patient. Int J Obstet Anesth 2007; 16: 74–6. 3. Ay H, Buonanno F S, Schaefer, et al. Posterior leukoencephalopathy without severe hypertension. Neurology 1998; 51: 1369–76. 0959-289X/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2007.11.003
Cardiac arrest during caesarean section for twins We would like to report a case of cardiac arrest during elective caesarean section under general anaesthesia. A 30-year-old (G4,P2) previously fit woman with a dichorionic, diamniotic twin pregnancy was admitted at 37 weeks of gestation for elective caesarean section. Her previous obstetric history consisted of a forceps-assisted vaginal delivery, termination of pregnancy and elective caesarean section for unstable lie. The previous caesarean section was carried out under uncomplicated combined spinal-epidural (CSE) anaesthesia. Her past medical history included hypothyroidism, pregnancy-induced impaired glucose tolerance and pregnancy-induced hyperemesis. Her thyroid function tests and blood glucose levels were normal at admission. Throughout pregnancy she had taken thyroxine daily and cyclizine intermittently for nausea. She did not report any specific symptoms of aortocaval compression during the pregnancy. Pre-operative physical examination was unremarkable and her booking BMI was 30 kg/m2. She consented to caesarean section under CSE anaesthesia. Regional blockade was attempted unsuccessfully by two anaesthetists, a trainee anaesthetist under supervision and a consultant. Neither could locate the epidural or subarachnoid space. The procedure was attempted in the sitting position although adequate positioning was difficult given the relatively large uterus. Following discussion with the patient, the decision was made to proceed with general anaesthesia. After 3-min pre-oxygenation, during which time there were no symptoms of aortocaval compression, anaesthesia was induced using a rapid sequence technique with thiopental 450 mg and suxamethonium 100 mg. The patient was monitored with an ECG, pulse oximetry and non-invasive blood pressure recorded every 2.5 min. End-tidal carbon dioxide, anaesthetic agent and oxygen were ana-
C. Rowley, J. Onslow lysed. The trachea was easily intubated and anaesthesia maintained with 0.8% isoflurane in 40% oxygen and 60% nitrous oxide via a circle system. Left lateral tilt of 15 was maintained throughout by table tilt. Immediately after intubation a brief period of desaturation to 90% occurred. This resolved quickly following manual ventilation with oxygen and 1% isoflurane. Tube position was rechecked by laryngoscopy and auscultation. A sinus tachycardia of 120 beats/min developed with a blood pressure of 140/80 mmHg. Approximately 1 min later arterial saturation dropped to 84%. Tube position and adequate ventilation were again confirmed as before and again the situation resolved quickly with ventilation with oxygen and 1% isoflurane. Further desaturation was observed 1-2 min later, but this time with complete loss of capnograph trace and carotid artery pulsation. Sinus tachycardia persisted at 120 beats/min and the patient appeared cyanosed. Cardiac massage was started and both babies were delivered within a further 45 s. Immediately after delivery the patient once again appeared well perfused, the capnograph tracing returned and carotid pulsation was felt. The blood pressure at this stage was recorded at 100/60 mmHg with a sinus tachycardia of 124 beats/min and arterial oxygen saturations of 100% with a FiO2 of 1.0. Throughout the case a total of 2000 mL of lactated Ringer’s solution was infused. Oxytocin 5 units and co-amoxiclav 1.2 g were given i.v. immediately post partum. The patient remained stable throughout the rest of the procedure. She was extubated and recovered without further adverse events. She was transferred to a two-bed recovery ward and observed by a trained recovery nurse. Postoperative ECG tracing showed a sinus tachycardia of 100 beats/min but was otherwise normal. Both twins had Apgar scores of 5 at 1 min and 9 at 10 min. The babies’ weights were 3080 and 3860 g and their umbilical artery pH values were 7.17 and 7.18 and base excess -8.2 and -6.9 mEq/L respectively. In this case the cardiac arrest coincided with the application of fundal pressure by the surgical assistant and resolved immediately post partum. In retrospect it would appear that the earlier desaturations also occurred following pressure on the abdomen as the surgical team pushed the gravid uterus back onto the inferior vena cava; this pressure was removed when surgery was stopped to correct what was considered to be an anaestheticrelated problem. In this case it is most likely that despite left lateral tilt, aortocaval compression was extreme, and the addition of fundal pressure was enough to precipitate a pulseless-electrical-activity
Correspondence
197
cardiac arrest. The occurrence of aortocaval compression in pregnancy is well documented,1 and left lateral tilt is now the standard accepted practice.2 However, this case highlights the fact that, despite what would usually be considered adequate left lateral tilt of 15,3 potentially fatal problems can still arise, especially in the presence of multiple pregnancy. Ben Gupta Anaesthetic SHO E-mail: [email protected] Emma Hartsilver Consultant Obstetric Anaesthetist Royal Devon and Exeter Hospital
References 1. Goodlin R C. Importance of the lateral position during labour. Obstet Gynecol 1971; 37: 698–701. 2. Levy D M. Emergency Caesarean Section: best practice. Anaesthesia 2006; 61: 786–91. 3. Kinsella S M. Lateral tilt for pregnant women: why 15 degrees? Anaesthesia 2003; 58: 835–6. 0959-289X/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2007.11.004
Anaesthesia for emergency caesarean section in a woman with 3M syndrome 3M syndrome is a rare autosomal recessive disorder characterised by proportionate dwarfism, dysmorphic facial features and characteristic radiological abnormalities. We would like to report a case of a woman with 3M syndrome who required urgent caesarean section. The woman, a 33-year-old primigravida, was referred by the obstetric team for anaesthetic review at 34 weeks of gestation. Delivery by elective caesarean section was planned for 38 weeks. The woman had been diagnosed with 3M syndrome when 10 years old. She gave a history of low back pain that had been investigated by rheumatologists who considered it to be most likely related to her marked lordosis and possible spinal stenosis. X-rays at this time had revealed some vertebral end-plate irregularities at her lower thoracic spine, and abnormal elongation of the upper lumbar vertebrae. She had undergone several previous general anaesthetics for lower limb operations, and did not report any anaesthetic problems. Her old notes were not available. In the past she had also been investigated for obstructive sleep apnoea because
of snoring, but sleep studies had been normal. On examination she was 139 cm tall with a BMI of 49 kg/m2. She had a short neck, a small chest and a short vertebral column, with marked lumbar lordosis and a narrowed pelvis. She did not have any neurological deficit. She had a Mallampati class 1 airway, good mouth opening and neck movement, and a temporo-mandibular distance of more than 6 cm. She was told that she would probably require general anaesthesia for the caesarean section but that other options would be further investigated. Unfortunately a literature search failed to provide information on spinal anatomy or the safety of either regional or general anaesthesia in patients with 3M syndrome. The woman was admitted in early labour at 36 weeks, two weeks before the date of her planned delivery. The obstetricians decided to proceed with urgent caesarean section. With the lack of information regarding the safety of regional anaesthesia, general anaesthesia was planned. Antacid prophylaxis with 30 mL 0.3M sodium citrate was given. Ranitidine had not been given. The woman was placed supine with left tilt and a 16-gauge intravenous cannula inserted. Monitoring included ECG, non-invasive blood pressure and pulse oximetry. After pre-oxygenation for 3 min, a rapid sequence induction was performed using thiopentone and suxamethonium. On the first attempt at laryngoscopy, a Cormack and Lehane grade 3 view was obtained; the view was not improved by optimising head and neck position. The trachea was intubated with a size-6 tracheal tube with the aid of a bougie. Anaesthesia was maintained with oxygen, nitrous oxide and isoflurane. A live baby with Apgar scores of 9 and 9 at 1 and 5 min respectively was delivered, after which 5 units of oxytocin (Syntocinon) were given intravenously, and a 40-unit infusion of Syntocinon in 500 mL 0.9% sodium chlorine was started at 125 mL/h. The woman was also given one dose of cefuroxime 1.5 g, morphine 10 mg i.v. and diclofenac 100 mg rectally at the end of surgery. She received a total of 1000 mL Hartmann’s solution and 500 mL Gelofusin intraoperatively. She was extubated awake and on her left side. Postoperative analgesia was provided with regular paracetamol and diclofenac, and morphine as needed. She was observed on the obstetric high-dependency unit for the first 4 h postoperatively and then transferred to the post-natal ward. Her postoperative course was uneventful apart from a wound infection, which was treated with oral antibiotics. 3M syndrome is also know as dolichospondylytic syndrome, gloomy syndrome, and Le Merrer syndrome.1 The name 3M is derived from the initials of the three people who first described it, Miller, McKusick and Malvaux.2 Fewer than 100 patients have been reported to have the condition in the world
References 1. Torrillo T M, Bronster D J, Beilin Y. Delayed diagnosis of posterior reversible encephalopathy syndrome (PRES) in a parturient with preeclampsia after inadvertent dural puncture. Int J Obstet Anesth 2007; 16: 171–4. 2. Prout P E, Tuckey J P, Giffen N J. Reversible posterior encephalopathy syndrome in a peripartum patient. Int J Obstet Anesth 2007; 16: 74–6. 3. Ay H, Buonanno F S, Schaefer, et al. Posterior leukoencephalopathy without severe hypertension. Neurology 1998; 51: 1369–76. 0959-289X/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2007.11.003
Cardiac arrest during caesarean section for twins We would like to report a case of cardiac arrest during elective caesarean section under general anaesthesia. A 30-year-old (G4,P2) previously fit woman with a dichorionic, diamniotic twin pregnancy was admitted at 37 weeks of gestation for elective caesarean section. Her previous obstetric history consisted of a forceps-assisted vaginal delivery, termination of pregnancy and elective caesarean section for unstable lie. The previous caesarean section was carried out under uncomplicated combined spinal-epidural (CSE) anaesthesia. Her past medical history included hypothyroidism, pregnancy-induced impaired glucose tolerance and pregnancy-induced hyperemesis. Her thyroid function tests and blood glucose levels were normal at admission. Throughout pregnancy she had taken thyroxine daily and cyclizine intermittently for nausea. She did not report any specific symptoms of aortocaval compression during the pregnancy. Pre-operative physical examination was unremarkable and her booking BMI was 30 kg/m2. She consented to caesarean section under CSE anaesthesia. Regional blockade was attempted unsuccessfully by two anaesthetists, a trainee anaesthetist under supervision and a consultant. Neither could locate the epidural or subarachnoid space. The procedure was attempted in the sitting position although adequate positioning was difficult given the relatively large uterus. Following discussion with the patient, the decision was made to proceed with general anaesthesia. After 3-min pre-oxygenation, during which time there were no symptoms of aortocaval compression, anaesthesia was induced using a rapid sequence technique with thiopental 450 mg and suxamethonium 100 mg. The patient was monitored with an ECG, pulse oximetry and non-invasive blood pressure recorded every 2.5 min. End-tidal carbon dioxide, anaesthetic agent and oxygen were ana-
C. Rowley, J. Onslow lysed. The trachea was easily intubated and anaesthesia maintained with 0.8% isoflurane in 40% oxygen and 60% nitrous oxide via a circle system. Left lateral tilt of 15 was maintained throughout by table tilt. Immediately after intubation a brief period of desaturation to 90% occurred. This resolved quickly following manual ventilation with oxygen and 1% isoflurane. Tube position was rechecked by laryngoscopy and auscultation. A sinus tachycardia of 120 beats/min developed with a blood pressure of 140/80 mmHg. Approximately 1 min later arterial saturation dropped to 84%. Tube position and adequate ventilation were again confirmed as before and again the situation resolved quickly with ventilation with oxygen and 1% isoflurane. Further desaturation was observed 1-2 min later, but this time with complete loss of capnograph trace and carotid artery pulsation. Sinus tachycardia persisted at 120 beats/min and the patient appeared cyanosed. Cardiac massage was started and both babies were delivered within a further 45 s. Immediately after delivery the patient once again appeared well perfused, the capnograph tracing returned and carotid pulsation was felt. The blood pressure at this stage was recorded at 100/60 mmHg with a sinus tachycardia of 124 beats/min and arterial oxygen saturations of 100% with a FiO2 of 1.0. Throughout the case a total of 2000 mL of lactated Ringer’s solution was infused. Oxytocin 5 units and co-amoxiclav 1.2 g were given i.v. immediately post partum. The patient remained stable throughout the rest of the procedure. She was extubated and recovered without further adverse events. She was transferred to a two-bed recovery ward and observed by a trained recovery nurse. Postoperative ECG tracing showed a sinus tachycardia of 100 beats/min but was otherwise normal. Both twins had Apgar scores of 5 at 1 min and 9 at 10 min. The babies’ weights were 3080 and 3860 g and their umbilical artery pH values were 7.17 and 7.18 and base excess -8.2 and -6.9 mEq/L respectively. In this case the cardiac arrest coincided with the application of fundal pressure by the surgical assistant and resolved immediately post partum. In retrospect it would appear that the earlier desaturations also occurred following pressure on the abdomen as the surgical team pushed the gravid uterus back onto the inferior vena cava; this pressure was removed when surgery was stopped to correct what was considered to be an anaestheticrelated problem. In this case it is most likely that despite left lateral tilt, aortocaval compression was extreme, and the addition of fundal pressure was enough to precipitate a pulseless-electrical-activity
Correspondence
197
cardiac arrest. The occurrence of aortocaval compression in pregnancy is well documented,1 and left lateral tilt is now the standard accepted practice.2 However, this case highlights the fact that, despite what would usually be considered adequate left lateral tilt of 15,3 potentially fatal problems can still arise, especially in the presence of multiple pregnancy. Ben Gupta Anaesthetic SHO E-mail: [email protected] Emma Hartsilver Consultant Obstetric Anaesthetist Royal Devon and Exeter Hospital
References 1. Goodlin R C. Importance of the lateral position during labour. Obstet Gynecol 1971; 37: 698–701. 2. Levy D M. Emergency Caesarean Section: best practice. Anaesthesia 2006; 61: 786–91. 3. Kinsella S M. Lateral tilt for pregnant women: why 15 degrees? Anaesthesia 2003; 58: 835–6. 0959-289X/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2007.11.004
Anaesthesia for emergency caesarean section in a woman with 3M syndrome 3M syndrome is a rare autosomal recessive disorder characterised by proportionate dwarfism, dysmorphic facial features and characteristic radiological abnormalities. We would like to report a case of a woman with 3M syndrome who required urgent caesarean section. The woman, a 33-year-old primigravida, was referred by the obstetric team for anaesthetic review at 34 weeks of gestation. Delivery by elective caesarean section was planned for 38 weeks. The woman had been diagnosed with 3M syndrome when 10 years old. She gave a history of low back pain that had been investigated by rheumatologists who considered it to be most likely related to her marked lordosis and possible spinal stenosis. X-rays at this time had revealed some vertebral end-plate irregularities at her lower thoracic spine, and abnormal elongation of the upper lumbar vertebrae. She had undergone several previous general anaesthetics for lower limb operations, and did not report any anaesthetic problems. Her old notes were not available. In the past she had also been investigated for obstructive sleep apnoea because
of snoring, but sleep studies had been normal. On examination she was 139 cm tall with a BMI of 49 kg/m2. She had a short neck, a small chest and a short vertebral column, with marked lumbar lordosis and a narrowed pelvis. She did not have any neurological deficit. She had a Mallampati class 1 airway, good mouth opening and neck movement, and a temporo-mandibular distance of more than 6 cm. She was told that she would probably require general anaesthesia for the caesarean section but that other options would be further investigated. Unfortunately a literature search failed to provide information on spinal anatomy or the safety of either regional or general anaesthesia in patients with 3M syndrome. The woman was admitted in early labour at 36 weeks, two weeks before the date of her planned delivery. The obstetricians decided to proceed with urgent caesarean section. With the lack of information regarding the safety of regional anaesthesia, general anaesthesia was planned. Antacid prophylaxis with 30 mL 0.3M sodium citrate was given. Ranitidine had not been given. The woman was placed supine with left tilt and a 16-gauge intravenous cannula inserted. Monitoring included ECG, non-invasive blood pressure and pulse oximetry. After pre-oxygenation for 3 min, a rapid sequence induction was performed using thiopentone and suxamethonium. On the first attempt at laryngoscopy, a Cormack and Lehane grade 3 view was obtained; the view was not improved by optimising head and neck position. The trachea was intubated with a size-6 tracheal tube with the aid of a bougie. Anaesthesia was maintained with oxygen, nitrous oxide and isoflurane. A live baby with Apgar scores of 9 and 9 at 1 and 5 min respectively was delivered, after which 5 units of oxytocin (Syntocinon) were given intravenously, and a 40-unit infusion of Syntocinon in 500 mL 0.9% sodium chlorine was started at 125 mL/h. The woman was also given one dose of cefuroxime 1.5 g, morphine 10 mg i.v. and diclofenac 100 mg rectally at the end of surgery. She received a total of 1000 mL Hartmann’s solution and 500 mL Gelofusin intraoperatively. She was extubated awake and on her left side. Postoperative analgesia was provided with regular paracetamol and diclofenac, and morphine as needed. She was observed on the obstetric high-dependency unit for the first 4 h postoperatively and then transferred to the post-natal ward. Her postoperative course was uneventful apart from a wound infection, which was treated with oral antibiotics. 3M syndrome is also know as dolichospondylytic syndrome, gloomy syndrome, and Le Merrer syndrome.1 The name 3M is derived from the initials of the three people who first described it, Miller, McKusick and Malvaux.2 Fewer than 100 patients have been reported to have the condition in the world