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UCSF

October 23, 2014

Mark Rollins, MD, PhDUCSF Director Obstetric Anesthesia

UCSFOB/GYN Update:What Does the

Evidence Tell Us?

Discussion of ACLS considerations in pregnancy…

• Frequency of Cardiac Mortality

• ACLS Code Modifications

• Local Anesthetic Toxicity

• Perimortem Delivery

• Checklists & Simulation

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

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Causes of pregnancy-related death in the United States: 2006–2010

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

Anesthesiology, June 2014

Anesthesiology, June 2014

Cardiac Arrest: 1 in 7,151 (CI 1:5,319 - 1:9,615)

Eric J. Lavonas, Farida M. Jeejeebhoy and Andrea GabrielliTerry L. Vanden Hoek, Laurie J. Morrison, Michael Shuster, Michael Donnino, Elizabeth Sinz,

Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular CarePart 12: Cardiac Arrest in Special Situations: 2010 American Heart Association

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Cardiac arrest in pregnancy• Incidence:

1:20,000 patients• Mostly: stick to

ACLS algorithms• IV above

diaphragm• Difficult airway• Left uterine

displacement• Cesarean section

• How Does This Consensus Statement Differ From Existing Guidelines?

Anesth & Analg, June 2014

Key Objectives

• Appropriate Team

• Relieve Aorto-Caval Compression

• Focus on Chest Compressions

• Do Not Delay Defibrillation

• Prepare for Emergent Delivery

• Checklists and Simulation

Call for Help“Code OB”

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Call for Help“Hey, Who’s resuscitating the baby?”

Cardiology, Anesthesia, Obstetricians & Nurses:

Can you use that pressor?

Should we stop the nitro drip?

I thought Versed was a teratogen…

The phenylephrine is causing the decels…

Isn’t supplemental oxygen bad for the baby?

Why are you tilting her to the left?

The loss of variability is just the fentanyl…Are you sure you want a stent placed? You won’t be able to place an epidural for delivery…

Where did all this fluid come from?

Slide by Elizabeth Whitlock

Aortocaval compression• The gravid uterus compresses the

IVC and aorta when supine• Hypovolemic shock

Kerr MG: Cardiovascular dynamics in pregnancy and labor. BMJ Bull 24:19, 1968.

Slide by Elizabeth Whitlock

Left uterine tilt/displacement

Slide by Elizabeth Whitlock Vanden Hoek. Circulation; 122:S829. 2010

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Left uterine tilt/displacement

Lift!

Displace!

Slide by Elizabeth Whitlock Vanden Hoek. Circulation; 122:S829. 2010

Cardiac arrest in pregnancy: CABDE• C: Circulation▫ Left uterine displacement▫ Compressions� 2 or 3 cm Higher on Sternum� 5-cm depth (Hard)� 100/min (Fast)� Rotate Compressors q 2 min� Minimize Interruptions� Capnography (> 10 mmHg)

▫ IV above the diaphragmF.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809

Slide by Elizabeth Whitlock

Airway and Breathing

• An example of a

“simplified algorithm”

• Call for Help

• Don’t get fixated on ETT placement

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Airway and Breathing

• 10 breaths per min.

• 500-700 ml/breath

• EtCO2 confirmation

Cardiac arrest in pregnancy: CABDE• D: Defibrillate:

• Performed on shockablerhythms ASAP

• No change in energy during pregnancy

• AED?

• Goal of < 3 min from collapse

• Removal of monitors

Slide by Elizabeth Whitlock

Cardiac arrest in pregnancy: CABDE

•D: Drugs:

• All ACLS drugs OK

• Oxytocin?

• Lipid Emulsion with Local Anesthetic Toxicity

Perioral Numbness or TinglingMetallic Taste

Tinnitus DiplopiaLightheadedness

Confusion & DrowsinessRestlessness

Sense of Impending DoomMuscular Twitching

Tonic-Clonic SeizuresUnconsciousness

Respiratory Arrest

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Tachycardia

Hypertension

Myocardial Depression

Decreased Cardiac Output

Peripheral Vasodilation

Hypotension

Conduction Block

Sinus Bradycardia

Ventricular Arrhythmias

Asystole Collapse

• Advanced Age

• Severe Cardiac Dysfunction

• Conduction Abnormalities

• Liver Disease

• Low Plasma Protein

• AcidosisNeal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8

Neal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8 Neal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8

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Neal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8

Anesth Analg. February 2013

Anesth Analg. April 2012

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BMJ. December 2003

Cardiac arrest in pregnancy: CABDE

• E: Extract (the fetus)▫ Incision at 4 minutes▫ Delivery by 5 minutes

post-arrest

Slide by Elizabeth Whitlock

No perfusing rhythm after 4 minutes?

Perimortem cesarean section Perimortem cesarean section

American Journal of Obstetrics and Gynecology (2005) 192, 1916–21

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Perimortem cesarean section

American Journal of Obstetrics and Gynecology (2005) 192, 1916–21

Perimortem cesarean section

American Journal of Obstetrics and Gynecology (2005) 192, 1916–21

Perimortem cesarean section

• Location?

• Operative Vaginal Delivery?

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AJOG; 203:179.41-5. 2010

Anesth & Analg. 118(5):1003 Anesth & Analg. 118(5):1003

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EMERGENCY MANUAL

COGNITIVE AIDS FOR OB PERIOPERATIVE CRITICAL EVENTS

Adapted from: Stanford Anesthesia Cognitive Aid Group’s Emergency Manual 2014, V2.0 and Gawande et al. OR Crisis Checklists NEJM 2013; 368: 246-53.

CH

EC

KLI

ST

S

Adapted from: Stanford Anesthesia Cognitive Aid Group’s Emergency Manual 2014, V2.0 and Gawande et al. OR Crisis Checklists NEJM 2013; 368: 246-53.

ACLSAsystole/PEA……………………………………………………..…....1Bradycardia – Unstable……………………………………..……..2Tachycardia – Unstable……………………………………..……..3Pulseless VF/VT……………………………………………..…………4CRITICAL EVENTS: NON-ACLSAmniotic Fluid Embolism………………………………..………..5Anaphylaxis…………………………………………………..…………6Bronchospasm…………………………………………….….……….7Difficult airway – Unanticipated………………….…………..8Fire…………………………………………………………….………..….9Post-partum Hemorrhage…………………………….…….….10Hypotension………………………………………………...………..11Hypoxia……………………………………………………..….……….12Local Anesthetic Toxicity……………………..………….……..13Malignant Hyperthermia…………………………………………14Myocardial Ischemia……………………………………………….15Tachycardia – Stable SVT………………………………….…….16Total Spinal Anesthesia………………………………….……….17Transfusion Reaction…………………………………….……….18Venous Air Embolus……………………………………………….19

Are you seeking to help clinicians deliver the best possible care during medical

emergencies?

Despite best intentions, well-trained clinicians often miss known key steps during

critical events.

This FREE perioperative Emergency Manual contains 25 critical events as well as

Crisis Resource Management key points. It has been iteratively tested with simulation

over many years.

Table of ContentsMobile DownloadPermissions & Local CustomizationAppropriate CitationDisclaimer

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Potential Drills & Simulations

Severe Fetal Bradycardia

Eclamptic Seizure

Shoulder Dystocia

Massive Hemorrhage

Failed Intubation

Anaphylaxis

Total Spinal

Magnesium Overdose

Opportunities for New Facilities

Where are the supplies located? Airway cart? Code cart?

What are the work flows?

How long does it take to transfer patient locations?

How do I call for help? A code? A crash?

How do I get emergency blood?

How do I get STAT labs? Point of care testing?

Preston P, et al. Seminars in Perinatology 2011. 35:84

• Cardiac Arrest in Pregnancy is Rare

• Appropriate Help “Code OB”

• Relieve Aorto-Caval Compression

• Focus on Compression & Defibrillation

• Use Lipid Emulsion with LAST

• Prepare Early for Emergent Delivery

• Checklists and Simulation Beneficial