Transcript perioperative management of a parturient with prior h/o pulmonary

PERIOPERATIVE MANAGEMENT OF A
PARTURIENT WITH PRIOR H/O
PULMONARY EMBOLISM AND IVC
FILTER IN SITU
DR.KRANAPPU SOLOMON,DNB PG
DR.RENU DEVAPRASATH,DNB (Anesth)
DR.V.SANKARASUBRAMANIAN,M.D.(Anesth)
DR.JEYASEKHARAN HOSPITAL &NURSING HOME,
NAGERCOIL
CASE SCENARIO
 21 year old primi came to our hospital at 7th month of
gestation for antenatal checkup.
 Gave past h/o superior sagittal sinus thrombosis 4
years back.
 Mild antithrombin III deficiency & was on
tab.Warfarin
 H/o iliofemoral deep venous thrombosis extending
into IVC upto renal veins level.
 H/o pulmonary embolism, thrombolysed and
prophylactic permanent transjugular IVC filter
deployed prior to discharge with oral anticoagulants.
ANTENATAL SCENARIO
 As soon as pregnancy was
confirmed warfarin was
stopped,started on inj.fondaparinux
2.5mg OD sc as per physician
advice.
 Antenatal checkup continued in our
hospital.
 Advised to get admitted 3days prior
to anticipated time of delivery.
PREOPERATIVE PREPARATION
 Coagulation workup done
 Adequate fresh blood & fresh frozen
plasma arranged
 Inj.Fondaparinux stopped 48 hours
prior to elective LSCS.
 Risk of maternal haemorrhage &
recurrent DVT/ PE in the postop.
period explained.
 Discussed with Obstetrician.
ANESTHETIC MANAGEMENT
 Two peripheral IV lines secured
 Informed consent obtained for regional anaesthesia
 SUBARACHNOID BLOCK
sitting position,
L3-4 level
27G Quincke needle
Single shot
Drug: 0.5% Bupivacaine 2ml + 0.1mg morphine
 Intraop-uneventful
Full term baby delivered
POSTOP.MANAGEMENT
 Analgesia lasted for 20 hours.
 Inj.Fondaparinux started after 24
hours.
 Tab.Warfarin restarted.
 PT,INR checked & maintained
around 2.5-3.5
 Patient had an uneventful postop. &
discharged home.
DISCUSSION
Be prepared to take the new role
as perioperative physician.
Update on new drugs essential
-FONDAPARINUX.
Patient on anticoagulants: plan
early to avoid mishaps.
Pregnancy:high risk of DVT/PE
IVC Filter.
Anaesthetic technique of choice –
choose the best technique that
suits the patient and of course you.
ANSWERS FOR THE ANTICIPATED
PROBLEMS
 Maternal bleeding.
 Emergency caesarean.
 Recurrent DVT/PE.
 Dislodgement of IVC filter?



Anaesthesiology Clinics .vol.26,pg.1-22
Anaesthesiology Clinics of North America. vol.21,pg.99,165
Evidence-Based Practice Of Anesthesiology. Lee A.Fleisher ,pg.218.