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Intraoperative use of Point of Care Ultrasonography (POCUS) for Stat Cesarean Delivery with Refractory Hypoxemia
Abstract Number: F-64
Abstract Type: Case Report/Case Series
Background: A 30-year-old, 131kg, BMI 43, G6P5 female at 24 weeks gestation presented with complaints of headache, hypertension and blurry vision. She was diagnosed with superimposed pre-eclampsia (SIPE) on chronic hypertension. An obstetrical emergency was called due to fetal heart rate decreasing to a nadir of 40bpm within 20 minutes of arrival. The patient was taken for an emergent cesarean delivery requiring general anesthesia.
Intraoperative Course: Prior to induction of anesthesia, the SpO2 was 92% on 6L O2 facemask and 93% on 100% mask preoxgenation. A rapid sequence induction was conducted with a successful intubation using a videofibroptic scope with end tidal CO2 confirmation and bilateral breath sounds. Oxygen saturation during laryngoscopy decreased to 80%. Immediately after intubation, SpO2 dropped to 71% on 100% Fio2. The patient was manually ventilated and she was given Albuterol endotracheally.The endotracheal tube was withdrawn 1 cm with reconfirmation of breath sounds. The oxygen saturation remained between 71-80% using manual ventilation. Peak airway pressure ranged from 25-38mmHg while an attempted machine ventilation. At that time, the differential diagnosis included bronchospasm, pneumothorax, pulmonary edema, cardiogenic congestive heart failure, hemothorax, atelectasis and pneumonia. In order to assist in diagnosing and planning further anesthetic treatment, a portable point-of-care ultrasound (POCUS) device was brought into the operating room. Using the Focused Assessed Transthoracic Echocardiography (FATE) protocol, windows obtained suggested that the patient had a small pericardial effusion, left ventricular hypertrophy and gross pulmonary edema as illustrated by multiple “b-lines” in pleural view (Images). Given the findings, 1:1 crystalloid replacement was undertaken rather than the traditional 3:1 replacement for crystalloid to blood loss ratio. The patient’s SpO2 slowly improved and by the end of the surgical procedure as SpO2 was between 88-91%. Re-imaging of the pleural views revealed some improvement of interstitial pulmonary fluid. The patient remained intubated for the entire procedure and post-operatively.
Results and Postoperative Course: A chest radiograph postoperatively confirmed ongoing pulmonary edema and equivocal pleural and pericardial effusions. A transthoracic echo obtained on postoperative day (POD) 1 further supported the diagnosis. The patient was extubated on POD 2 and eventually discharged home. The patient was scheduled for follow-up care.
Conclusion: Peri-operative POCUS was used to help aid in a diagnosis of a emergent cesarean delivery with ongoing hypoxia. Multiple medical disciplines, including obstetrics, anesthesia and critical care, were able to visualize her problems and collaborate. The images obtained gave a focal point to continue her post operative care. Further study to broadening obstetrical anesthesia use of POCUS is required.