Transcript Obstetric Anesthesia Rural NDANA

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OBSTETRIC ANESTHESIA
In the Rural Setting. . .and
What’s New in Obstetric
Anesthesia
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Sarah Bergakker CRNA, MSN
“Director” of Obstetric Anesthesia Spectrum Health
Gerber Memorial
[email protected]
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My Morning Traffic Jam
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(The traffic isn’t the only thing
that is different when
practicing as a CRNA in the
rural setting)
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CASE STUDY
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CRNA on call notified in the
evening
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Adolescent G 1 P 0, 34 wks
gestation female to ER by
ambulance
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Run over and dragged by
motor vehicle
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To Radiology for trauma scans
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Returns to OR for uncontrolled
bleeding in abdomen and
pelvis
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Massive transfusion
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Obstetrician and General
Surgeon achieve hemostasis
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Transported intubated by
helicopter to tertiary care
center
From ER to OR for Emergency
C-section
Mother becomes
hemodynamically unstable in
PACU
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Why do small hospitals even provide
obstetric care?
“Currently, approximately
34% of hospitals
providing obstetric care
have fewer than 500
deliveries per year”
ACOG Comm Opinion No. 344
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Why do small hospitals even
provide obstetric care?
“When geographic factors
require the existence of smaller
units, these units should be part
of a well-established regional
perinatal system”
ACOG Comm Opinion No. 344
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Critical Access vs. Community
Hospital
Critical Access
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25 or less licensed inpatient beds
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Located 35 miles drive from any
hospital (or 15 miles in rugged terrain)
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“Be located in a rural area or an area
treated as rural”
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Community Hospital
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No restriction on number of
licensed inpatient beds
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Located in any community,
anywhere
Average inpatient LOS 96 hrs (4 days)
or less
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No restriction on LOS
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Provide 24 hr ER service
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Bills medicare at regular rate
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Can bill Medicare patients at 101%
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Cannot be located in: Connecticut,
Delaware, Maryland, New Jersey, Rhode
Island
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Critical Access Hospitals Nationwide
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Nursing Education Loan
Repayment Program
http://goo.gl/DmTJdf
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Nursing Education Loan
Repayment Program

“The Nursing Education Loan Repayment Program will pay
60 percent of the participant’s total qualifying loan balance in
two years and an additional 25 percent of the original
balance for an optional third year. In order to qualify, NURSE
Corps members must fulfill a service obligation at any one of
the thousands of nonprofit hospitals, clinics and other
facilities located in designated primary medical care or
mental health Professional Shortage Areas across the U. S. ”
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Who’s Doing What Where
(Does not have to be an
anesthesiologist)
Chart graphic source: http://goo.gl/no92Pb
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Who’s Doing What Where
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The American Congress of
Obstetricians and Gynecologists
(and why they get to suggest how to do our job)
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ACOG issues opinions that
are used nationally as
guidelines for obstetric
care
Because safe delivery of
the baby, or resuscitation of
the mother may require
anesthesia care, CRNA
practice guidelines are
influenced by ACOG
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Examples
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There should be “availability of
anesthesia and surgical
personnel to permit the start of
a cesarean delivery within 30
minutes of the decision to
perform the procedure”
VBAC guidelines “Women and
their physicians may still make
a plan for a TOLAC in situations
where there may not be
“immediately available” staff to
handle emergencies, but it
requires a thorough discussion
of the local health care system,
the available resources, and the
potential for incremental risk”
ACOG committee opinion http://goo.gl/EUjwlj VBAC http://goo.gl/j35HNq
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!! IMMEDIATELY AVAILABLE !!
“The Definition of immediately
available personnel and facilities
remains a local decision based on
each institution’s available
resources and geographic
location.”
+ Obstetric Hemorrhage and Massive
Transfusion
+ Obstetric Hemorrhage and Massive
Transfusion
CALIFORNIA MATERNAL QUALITY CARE
COLLABORATIVE (CMQCC)
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Goal is to standardize monitoring for and care of the
hemorrhaging obstetric patient
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Identify patients at increased risk for obstetric hemorrhage
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QUANTIFY BLOOD LOSS via standardized system
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Stage 1 of hemorrhage protocol activated at > 500 ml blood loss
for vaginal delivery and > 1000 ml blood loss for cesarean
delivery
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includes ordering Type and Cross of 2 units PRBCs)
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Includes calling for additional help
OBSTETRIC HEMORRHAGE CARE SUMMARY: FLOW CHART FORMAT
Identify patients with special consideration:
Placenta previa/accreta, Bleeding disorder, or
those who decline blood products
Time of
admission
Screen All Admissions for hemorrhage risk:
Low Risk, Medium Risk and High Risk
Stage 0
All Births
Blood Loss:
>500 ml Vaginal
>1000 ml CS
Stage 1
Activate
Hemorrhage
Protocol
Blood Loss:
1000-1500 ml
Stage 2
Sequentially
Advance through
Medications &
Procedures
Blood Loss:
>1500 ml
Stage 3
Activate
Massive
Hemorrhage
Protocol
Follow appropriate workups, planning, preparing of
resources, counseling and notification
All women receive active management of 3rd stage
Oxytocin IV infusion or 10 Units IM
Vigorous fundal massage for 15 seconds minimum
Increase IV rate (LR); Increase Oxytocin
Methergine 0.2 mg IM (if not hypertensive)
Continue Fundal massage; Empty Bladder; Keep Warm
Administer O2 to maintain Sat >95%
Rule out retained POC, laceration or hematoma
Order Type & Crossmatch 2 Units PRBCs if not already done
Vaginal Birth:
Bimanual Fundal Massage
Retained POC: Dilation and Curettage
Lower segment/Implantation site/Atony: Intrauterine Balloon
Laceration/Hematoma: Packing, Repair as Required
Consider IR (if available & adequate experience)
Cesarean Birth:
Continued Atony: B-Lynch Suture/Intrauterine Balloon
Continued Hemorrhage: Uterine Artery Ligation
Unresponsive Coagulopathy:
After 10 Units PBRCs and full
coagulation factor replacement,
may consider rFactor VIIa
Verify Type & Screen on prenatal
record;
if positive antibody screen on prenatal
or current labs (except low level anti-D
from Rhogam), Type & Crossmatch 2
Units PBRCs
Low Risk: Hold clot
Medium Risk: Type & Screen, Review Hemorrhage Protocol
High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage
Protocol
Ongoing
Evaluation:
Quantification of
blood loss and
vital signs
NO
Standard Postpartum
Management
Fundal Massage
INCREASED BLEEDING
Activate Hemorrhage Protocol
CALL FOR EXTRA HELP
Continued heavy
bleeding
Increased
Postpartum
Surveillance
NO
YES
CALL FOR EXTRA HELP
Give Meds: Hemabate 250 mcg IM -orMisoprostol 800-1000 mcg PR
Transfuse 2 Units PRBCs per clinical
signs
Do not wait for lab values
Consider thawing 2 Units FFP
To OR (if not there);
Activate Massive Hemorrhage Protocol
Mobilize Massive Hemorrhage Team
TRANSFUSE AGGRESSIVELY
RBC:FFP:Plts à 6:4:1 or 4:4:1
Conservative Surgery
YES
NO
B-Lynch Suture/Intrauterine Balloon
Fertility Strongly
Uterine Artery Ligation
Desired
Hypogastric Ligation (experienced surgeon only)
Consider IR (if available & adequate experience) HEMORRHAGE CONTINUES
Cumulative Blood Loss
>500 ml Vag; >1000 ml CS
>15% Vital Sign change -orHR ≥110, BP ≤85/45
O2 Sat <95%, Clinical Sx
YES
Ongoing Cumulative Blood Loss Evaluation
PreAdmission
v 1.4 5/7/2010
Cumulative Blood Loss
>1500 ml, 2 Units Given,
Vital Signs Unstable
Increased
Postpartum
Surveillance
NO
Consider ICU
Care; Increased
Postpartum
Surveillance
Definitive Surgery
Hysterectomy
CONTROLLED
California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division
Obstetric Hemorrhage and
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Massive Transfusion
Specific Management Challenges for the Rural
Setting
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EARLY recognition of hemorrhage and well coordinated
response critical due to limited resources
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Limited practitioners available for “extra hands” response
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Know who and what your resources are
Limited blood products available
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Most rural hospitals will not have platelets available in house
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Some will not have cryoprecipitate
Structure should be in place for smooth transfer to tertiary
care center when indicated
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Cardiac Arrest in Pregnancy
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Extremely low frequency, extremely high acuity event
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Rate of 1:12,000 of hospitalizations for delivery
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Lower rate of occurrence in institutions with < 1000 deliveries/yr.
Common causes: hemorrhage, heart failure, amniotic fluid
embolism, and sepsis
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Reasons to Prepare for
Cardiac Arrest in Pregnancy
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Cause can be directly
anesthesia related and
reversible: Local anesthetic
toxicity, high spinal, failed
intubation, aspiration
Double the mortality for failed
response/resuscitation
Preparation and drills will help
identify overall ability of
obstetric and anesthesia
departments to respond to
emergencies in various
locations
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Hard to achieve goal of
incision in 4 minutes and
delivery in 5 without prior
practice simulations
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Facility factors associated with
75% of fatal outcomes
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Difficult to successfully
resuscitate mother until baby
is delivered
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Annual drills foster teamwork
between involved
departments
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Cardiac Arrest in Pregnancy
What’s Different?
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Perform manual left uterine
displacement (LUD)
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Remove internal and external fetal
monitoring equipment
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Prep the abdomen
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For third trimester patients place hands
higher on sternum (2-3 cm higher)
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If patient receiving magnesium stop
infusion and give calcium IV
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Defibrillation guidelines the same and
safe for fetus
What’s Different?
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IV access above diaphragm
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At 4 minutes post arrest proceed to
emergent ON LOCATION C-section
if no return of spontaneous
circulation (ROSC)
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Goal is delivery of baby within 5
minutes of cardiac arrest of mother
in absence of ROSC
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DO NOT move patient to the OR
 Time is lost
 Compressions and management
interrupted
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Remove LUD after delivery
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The Difficult Airway and Obstetrics
Any obstetric unit can quickly become “rural” in the sense of
location in the hospital and immediately available resources
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Induction of general anesthesia in the obstetric population
will result in failed intubation via direct laryngoscopy 1:300
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Induction of general anesthesia may be necessary for:
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Emergent c section
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Failed spinal or epidural
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Prolonged duration of operative procedure
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The Difficult Airway and Obstetrics
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Should always have a full airway setup ready to go in the
obstetric OR
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6.5 ETT and stylet
 Various sizes of ETT
Syringe for ETT cuff inflation
Two working handles
 One short
 One long
Miller 2 and Mac 3 blade
LMAs
Suction
Oral airways (avoid Nasal airways)
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The Difficult Airway and Obstetrics
The cost of obstetric unit dedicated
airway devices is minimal when
compared to adverse outcomes
associated with lack of immediately
available resources
The Difficult Airway and Obstetrics
IF UNABLE
TO
INTUBATE
OR
VENTILATE
DO NOT
PROCEED
TO CSECTION
DELIVERY!!!!
Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams &
Wilkins.
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The Difficult Airway and Obstetrics
STOP
THINK
COOMUNICATE
• ASSESS PATIENT, SITUATION
STATUS, AND RESOURCES
• THINK ABOUT WHAT YOU PLAN
TO DO NEXT
• TELL THE TEAM WHAT YOU
PLAN TO DO NEXT
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CASE STUDY
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24 yr. old G 1 P 0 in active
labor
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CRNA called in on a weekend
evening shift for urgent C
section for failure to progress
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Pt medical hx: 2 siblings have
died from “genetic
cardiomyopathy”
 Sibling one at age 2
 Sibling two at age 6
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First female of affected
cousins to have pregnancy
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Refused all maternal cardiac
testing
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Refused all fetal cardiac
testing
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Refused MFM workup
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Patient has cardiac Mets > 4
activity tolerance
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In labor and cannot be
transferred
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How would you proceed ???
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TRANSTHORACIC ECHO (TTE)
and why you should care to know about it
Provides a noninvasive, real-time method of
assessment superior to physical assessment
alone. TTE is not intended to replace
transesophageal echocardiography. The
purpose is provide an immediately available,
rapid assessment tool in the perioperative
setting.
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TRANSTHORACIC ECHO (TTE)
VIDEO
Video 1:18 4:04 6:16
https://www.youtube.com/watch?v=GcjFyRPlISw
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TRANSTHORACIC ECHO
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Increased image quality and
decreased cost of ultrasound
technology making TTE more and
more available
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“Goal Directed Therapy”
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Minimal technical training required
for successful technique
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Can be used any time during the
perioperative period to aid decision
making
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Qualitative assessment of valve
disorder severity
Assessment for intra operative
cardiovascular collapse
Rapid assessment in PACU of new onset
hemodynamic instability
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Addresses the “I wish I had an
ECHO” problem
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Anesthesia is late to the party
that ER and ICU started
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Non-invasive method to assess
hemodynamic status
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“Pocket Ultrasound will likely
replace your stethoscope” Dr.
J. T. Sullivan
+ Other Applications of Ultrasound in
Obstetric Practice
Identification of landmarks when placing epidural in patients with a high
BMI ( Video ) 2:25, 3:10, 3:36
https://www.youtube.com/watch?v=M4hiP46YMuc
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Other Applications of Ultrasound
in Obstetric Practice
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Pulmonary ultrasound
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Pulmonary edema
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Pneumothorax
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Pulmonary Effusion
Trans-ocular ultrasound
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Assess intracranial pressure
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Placement of cricothyrotomy
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Assessment of airway anatomy
Image Credit
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“Call the Midwife” (and get the nitrous)
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“Call the Midwife” (and get the nitrous)
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“Call the Midwife” (and get the nitrous)
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Used as early as 1881 in Poland for
labor analgesia
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United Kingdom 60% use
In 1934 self administration method
increases use
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Australia 50%
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1 % or less of U.S. births currently
using
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Finland and Canada about
50%
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Two major centers
 University of California, San
Francisco (> 30 yr. hx)
 Vanderbilt University Medical
Center
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*Data for home birth rates in
these countries would be of
interest
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Entonox® in Europe
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*Data for midwife delivery
rates also of interest
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Nitronox® in United States
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N2O use in the labor suite
is out there and
happening!
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“Call the Midwife” (and get the nitrous)
“CONS”
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Epidural decreases VAPS by 5 pts
or to around 3/10
“PROS”
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Not significantly higher rate of N&V
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Less sedating than Remifentanyl infusion
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Not as effective as Remifentanyl
infusion for analgesic effects
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Patients “like” it and would use it again – less
invasive
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What is scavenging system?
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Little/no negative neonatal effect
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Does not change uterine contractility
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Anti anxiety effects
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Patient can still ambulate
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Can be administered by nursing personnel
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Do not need continuous pulse oximetry – “minimal
sedation”
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Repeated staff exposure
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Maternal hypoxemia
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Studies do not show effective at
decreasing pain during labor
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May require CRNA resources to
manage
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“Call the Midwife” (and get the nitrous)
 Take
Away: If Nitrous Oxide
implementation occurs at your facility the
anesthesia department does not need to
necessarily manage daily setup and
administration in labor and delivery.
However, the anesthesia department should
be a key player in the development of
policies and procedures surrounding use
and implementation in labor and delivery.
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References:
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Department of Health and Human Services critical access hospital PDF http://goo.gl/Sxd8rt
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CMS.gov Centers for Medicare & Medicaid Services Critical Access Hosptials http://goo.gl/oUgQFv
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Nursing Education Loan Repayment Program http://goo.gl/DmTJdf
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CMS Manuel System Pub 100-07 State Operations Provider Certification http://goo.gl/no92Pb
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Critical Access Hospitals map and Statistics http://goo.gl/lKdZQf
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ACOG committee opinion Optimal Goals for Anesthesia Care in Obstetrics http://goo.gl/EUjwlj
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ACOG Today Aug 2010 New VBAC Guidelines http://goo.gl/j35HNq
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California Maternal Quality Care Collaborative http://goo.gl/ScC9Tf
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ASA Opinion Nitrous oxide for Labor http://goo.gl/sekMMM
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Nitrous Ocide for Labor Analgesia: Expanding Analgesic Options for Women in the United States M. R. Collins
et al. Reviews in Obstetrics & Gynecology Vol.5, No. ¾, 2012
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References:
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Limited transthroacic echocardiography assessment in anaesthesia and critical care. J. G. Faris et al.
Best Practice and Research Clinical Anaesthesiology 23 (2009) 285-298
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Obstetric Hemorrhage Care Guidelines: Flow Chart Format http://goo.gl/FuesBT
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California Maternal Quality Care Collaborative https://cmqcc.org/ob_hemorrhage
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The Society for Obstetric Anesthesia and Perinatology Consensus Statemetn on the Management of
Cardiac Arrest in Pregnancy. S. Lipman et al. Anesthesia and Analgesia. May 2014, Volume 118, number
5.
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Cardiac Arrest during Hospitalization for Delivery in the United States, 1998-2011. J. M. Mhyre et al.
Anesthesiology. 120:810-8.
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The Unanticipated Difficult Intubation in Obstetrics. J.M. Mhyre and D. Healy. Anesthesia and
Analgesia. March 2011. Volume 112. Number 3.