///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Effective Multidisciplinary Communication: A Look at Maximizing Patient Safety and Minimizing Patient Harm in a Medically and Surgically Complex Parturient

Abstract Number: 220
Abstract Type: Case Report/Case Series

Andrew D Rozbruch BA, DO1 ; Ellen Steinberg MD2; Joy Schabel MD3; Tracie Saunders MD4; Rishimani Adsumelli MD5

Recent review of closed claim analyses has shown poor communication among healthcare providers to be a growing and alarming trend among obstetric anesthesia malpractice claims. This case report illustrates the importance of how effective interdisciplinary communication can maximize patient safety and minimize patient harm. Our case involves a G1P0 parturient at 38 weeks gestation with a past medical history significant for breast cancer s/p bilateral mastectomy, chemotherapy and extensive flap reconstruction, superior vena cava syndrome, expanding brachial plexus mass, chronic pain syndrome, hypercoaguable disorder with bilateral internal jugular (IJ) vein clots, superior vena cava (SVC) clots and clots in the venous system of bilateral upper extremities. Upon admission to our institution, prior to planned induction of labor, the patient was seen by the obstetrical anesthesia staff for consultation. The main issues of concern regarding the care of this patient were adequate intravenous (IV) access, hypercoaguable status, early epidural placement, surgical back up should cesarean section be necessary, effective pain management, and logistical coordination of necessary resources and personnel. After interdepartmental discussion with Anesthesia, Obstetrics, Surgery, Interventional Radiology, Pain Management, Labor and Delivery personnel and Main OR staff, a plan for the care of this patient was established. IV access was particularly challenging in this patient. We were unable to use either upper extremity secondary to lymph node dissection from her mastectomy and extensive venous sclerosing from the chemotherapy; additionally, the patient had bilateral IJ clots, further limiting upper body access. We also wanted to avoid femoral access due to the high risk of clot formation and need for hip flexion for vaginal delivery. Prior to induction of labor, the patient was sent for placement of a PIC line with ultrasound guidance to ensure safe and secure access. Coordination with general surgery and their availability for back-up was also arranged in the event of a c-section, as the patient had extensive mesh reconstruction in her abdomen secondary to flap reconstruction after her mastectomy. With the aforementioned contingencies arranged, the patient then received dinoprostone for induction of labor. Upon arrival to L&D, the patient received an epidural to manage her labor pain and provide a safe mode of anesthesia care in the event of a stat cesarean section. The patient was also placed on a hydromorphone PCA and fentanyl transdermal patch as prescribed by the acute pain service to manage her chronic axilla pain and opioid requirements. Over the course of the next 32 hours, the patients labor progressed without complications and the patient delivered vaginally. We plan to discuss the importance of interdepartmental communication in caring for a complicated patient such as ours to both maximize patient safety and minimize patient harm.

SOAP 2009