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Question: where i went wrong  (Voting closed: February 24, 2007, 08:19:31 PM)

  • IT COULD HAVE BEEN DONE UNDER GA
    - 3 (60%)
    UNDER EPIDURAL ANAESTHESIA
    - 1 (20%)
    WAS GIVING SINAL ANAESTHESIA OK
    - 1 (20%)

Total Members Voted: 5

Author Topic: how to manage a case of suspected heart disease undergoing LSCS UNDER SPINAL  (Read 10116 times)

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frontier

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SIR,
    I,DR.SIMANT KUMAR JHA, GAVE SPINAL ANAESTHESIA IN A CASE OF LSCS.LADY WAS 35 YR OLD.IT WAS HER THIRD ISSUE.IT WAS A CASE OF IUD WITH PLACENTA PREVIA.I EXAMINED THE PATIENT.MY CVS FINDING WAS MITRAL AREA-1st HEART SOUND LOUD,TACHYCARDIA,PULMONARY AREA-P2 LOUD/I WAS NOT ABLE TO DETECT ANY MURMUR/CHEST AUSCULTATED-RT AXILLARY AREA-COARSE CREPITATIONS/AS PATIENT GAVE A HISTORY OF CHRONIC COUGH WITH DYSPNOEA ON EXERTION/ON TABLE PATIENT WAS BREATHLESS WITH SPO2-75%/ I THOUGHT IT WAS A CASE OF MITRAL STENOSIS WITH NO ECHO AVAILABLE/CHEST XRAY FINDING-CARDIOMEGALY,PROMINENT AORTIC KNUCKLE,VASCULAR MARKING PROMINENT IN RT HILAR REGION.
 I IMMEDIATELY SOUGHT A PHYSICIAN' OPINION/HE SAID IT WAS NOT A CASE OF VOLVULAR HEART DISEASE/AS IT WAS A CASE OF PLACENTA PREVIA TOO & PATIENT WAS NOT IN A POSITION TO SIT WITH CHANCES OF PROFUSE BLEEDING,I GAVE SPINAL ANAESTHESIA IN LEFT LATERAL POSITION IN L3-L4 SPACE WITH 25 GUAGE NEEDLE..5% BUPIVACAINE ONLY 2.5 ML GIVEN/PRE OP BP WAS 130/80 MM OF HG WITH 200 ML OF URINE OUTPUT/AS INCISION WAS GIVEN & DEAD BABY WAS TAKEN OUT.IT TOOK 20 MINUTES FOR THE SURGEON/IN THE MEANTIME I GAVE O2 THROUGH MASK CONTINUOUSLY/TWO IV LINES WERE SECURED/THROUGH 1 LINE FRESH BLOOD WAS BEING GIVEN & THROUGH ANOTHER LINE RL WAS GIVEN,PATIENT SUFFERED CARDIAC ARREST/IMMEDIATELY PATIENT WAS INTUBATED & CPR GIVEN/RT INTERNAL JUGULAR WAS CANNULATED/12 MG OF IV EPHEDRINE GIVEN/DOPAMINE IN 5% DEXTROSE STARTED/IV ATROPINE 5 AMPOULES AT REGULAR INTERVAL GIVEN WITH 2 AMPOULES OF DILUTED ADRENALINE USED/CARDIAC MASSAGE CONTINUED IN A RATIO OF 100 PER MINUTE WITH 10 VENTILATION PER MINUTE/AFTER 1/2 AN HOUR  OF CPR HEART STARTED BEATING ,BUT STILL NO SPONTANEOUS RESPIRATION/IT TOOK ANOTHER 1 HOUR FOR SPONTANEOUS RESPIRATION TO RETURN/IN THE MEANTIME IPPV GIVEN THROGH BAG/SPO2 FINALLY WAS 85%/PATIENT STILL HYPERVENTILATING WITH SLIGHT EXTENSOR RESPONSE/BOTH PUPIL WERE DILATED & SLUGGISHLY REACTING TO LIGHT/I SHIFTED THE PATIENT TO ICU/PUT ON VENTILATOR ON SIMV MODE/STARTED NORADRENALINE & DOBUTAMINE/WITH BP NONRECORDABLE/PATIENT REMAINED ON VENTILATOR FOR 5 HOURS/PATIENT WAS TO BE TAKEN TO AHIGHER CENTRE/WAS TAKEN OFF FROM VENTILATOR ,SUFFERED CARDIAC ARREST/COULDN'T BE REVIVED/I WANT TO KNOW where i went wrong?
   DR.SIMANT KUMAR JHA,RIMS,RANCHI,JHARKHAND,INDIA
« Last Edit: February 07, 2007, 07:46:19 PM by drsimant »
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Affertus

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........I WANT TO KNOW where i went wrong?.......

Situations like this are very difficult. Every decision can have positive or negative aspects, so is very difficult to find some error. Surely your conduct was accurated and precise. Personally I would have preferred a general anesthesia with intubation from the beginning. Remains to understand the reason of the desaturation and the tachycardia followed by cardiac arrest. Perhaps the patient had suffered of serious intrauterine hemorrhage with severe hypovolemya.
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Stefano Soriano from Italy My life in the depth of the sea
Sorry for my bad english ...... ;-)
http://www.stefano-soriano.it

frontier

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DEAR AFFERTUS,
           THANKS FOR YOUR SUGGESTION.PERSONALLY I TOO COULD HAVE OPTED FOR GA.BUT WE DON'T HAVE VERY GOOD SETUP.PATIENT WAS NOT HAVING ECHO REPORT,I TOOK HELP OF PHYSICIAN ON DUTY.I THOUGHT IT WAS A CASE OF MITRAL STENOSIS.PERHAPS WITH HEART FAILURE.BUT PHYSICIAN THOUGHT IT WAS NOT A HEART DISEASE.I GOT CONFUSED.I OPTED FOR SPINAL WITH MINIMAL DOSE OF BUPIVACAINE THINKING OF MINIMAL SYMPATHOLYSIS.MORNING TIME WHEN ECG WAS DONE.IT WAS SHOWING RT AXIS DEVIATION.ECHO WAS LIKELY TO BE DONE.BUT BY THAT TIME PATIENT DIDN'T SURVIVE.I COULDN'T DO MUCH.
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kumar

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same must have been under narcotic alone intrathecally.

I dont use 2.5ml of 0.5%bupivacaine.

I use 1.75ml of 0.5%bupivacaine plus 0.25ml of buprenorphine routinely.

0.5ml of buprenorphine in cardiac case
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hisho520

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hi every body,for this patient epidural was the best using both local anaesth and opioids
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frontier

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hi everyone,
    i want to know from all of you that probably it was a case of cardiomyopathy with heart failure as per the discussions in the meeting,so what could have been the ideal mode of anaesthesia?
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amarkatira

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first of all GA was the best option.sensorcain in a dose of 2ml.is more than adequate for LSCS
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ashok-jadon

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Dear friend,
                It is sruprising that you can opt for echo but you dont have anaesthesia machine ( i suppose as you have mentioned you dont have good set-up). 2.5 ml in cardiac patient is too much. you could have used less amount with addition of tidigesic, morphine or fentanyl if you have.
Continuous spinal or epidural would have been ideal choice, i have used continuous spinal in such cases my self, without complications.
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frontier

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hi,
  by writing we don't have a good setup it doesn't mean that we don't have basic anaesthesia machine/when patient suffered cardiac arrest how i could have managed the patient without anaesthesia machine?i mean to say we don't have a good ICU setup.Further to clarify before giving GA to such a bad case one always thinks of proper backup means if needed patient can be put on ventilator.we don't have a ventilator in recovery room & for your surprise only 1 ventilator in medicine ICU WHICH ALWAYS REMAINS OCCUPIED.on that very night i took help of anaesthesia machine & ventilated the patient manually for 2 hours when patient suffered cardiorespiratory arrest. As we don't have ventilator provided in our anaesthesia machine. anyhow on that fateful night one patient who was on ventilator in medicine ICU was weaned off & then i rushed my patient from OT to ICU.now hope you will come to know about the bad setup.now something about drugs even buprenorphine is hardly available & what to talk about fentanyl & morphine?  secondly mainly poor patients come to our hospital & the patient didn't go for a proper antenatal check up.patient was not having ECHO report & physician on duty ruled out the cardiac disease.so i treated the case as non cardiac one & i had to give anaesthesia without further loss of time as it was an emergency case .otherwise my mode of anaesthesia could have been different perhaps a GA or an epidural.thanking you.with regards.
« Last Edit: September 04, 2007, 02:45:09 AM by frontier »
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yogenbhatt1

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Being from India I know what it means to manage this kind of cases. PACU is an unheard word. Let us not discuss tirtiary care centers of Mumbai of Chennai. Over all the scene is same all over. Drugs still remain unavailable even in Mumbai( very rigid Narcotic dept).
Overall a very well managed scene in given situation. But the very fact, that the SPO2 was 75% preop, meant that there is real gross problem. Either a PH or high CVP due to anything. GA is real bad if you do not have support, as every one wants to balme you for death du to GA. Yes, retrospective wisdom says, that If we use Narcotics, or even Ketmin Midaz in spinal, it could have been ok. Epidural in slow increaments may be ok, but it takes time and that too if you are not used to giving it in lateral position. Yes, a continuous intrathecal is a best choice along with intra thecal narcotics or even Ketamine would have been best. We have to use only an 18G epidural cath for continuous spinal, as special sets are not easy to acquire. As suggested, now it looks more like a praganecy related cardiomyopathy. But it woukd have been bad either way.
I will add to this by saying that I thought GA should be a better option, so I gave GA in a tight mitral with PH, she came out very well, but every time I would extubate her she would arrest in next about 15 - 20 mins. It happerned thrice over next 15 days. She was fully conscious, but venti depenent. Eventually she had to undergo em. valve replacement, but succumbed to all this in next 15 days time, when they tried to extubate her in the best hospital of Mumbai.
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frontier

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dear dr. yogen
          i am really thankful to you atlast someone who understood the situation & my difficulties.thanks a lot.with regards
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