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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Something Old, Something Borrowed...

Abstract Number: S1C-7
Abstract Type: Case Report/Case Series

Mari Roberts MBChB MRCP FRCA1 ; Priya Thorat FRCA2; Ashley Parker FRCA3

Postpartum haemorrhage (PPH) kills 86,000 women annually. A loss of 40% of blood volume puts women into a “death zone”. Most fatalities occur in resource-poor countries (RPCs), where blood transfusion may be difficult. However, ethical refusal of blood, or the increasing prevalence of antibodies from past transfusion, can also render transfusion impossible in Western settings, where retained placenta and PPH rates are rising. General anaesthesia often worsens cardiovascular instability and uterine atony. An exception to this rule is Ketamine.

A 42 year old, G6P4 lady with complex psycho-social needs, presented in term labour. After her first Category 2 Caesarean section (CS), she subsequently had 3 successful vaginal births and a late miscarriage. Her antenatal haemoglobin (Hb) count was 111g/L. She was a Jehovah’s Witness, with a valid Advanced Directive, refusing blood transfusion.

After vaginal delivery of her 6th baby, she rapidly lost 2 litres of blood, in her delivery room. In Class 4 shock, she was barely rousable with a systolic blood pressure (SBP) of 50mmHg. After limited fluid resuscitation to a SBP of 80mmHg, the anaesthetist confirmed with the patient & her husband that they wished to refuse blood products at all costs.

The anaesthetist had worked in a RPC where grand multiparity was common and Ketamine was widely used as the sole agent. Thus, after pre-oxygenation, our patient received a modified rapid sequence induction with Midazolam 2mg, Fentanyl 50mcg, Ketamine 2mg/kg and Suxamethonium 100mg. Her trachea was intubated. Anaesthesia was maintained with intravenous Ketamine 2mg/kg every 15 minutes and an inhaled 50:50 oxygen / nitrous oxide mix. Limited crystalloid and a vasoconstrictor infusion kept her SBP to within 30mmHg of normal. She was aggressively warmed and all acceptable haemostatic products were given to treat the visible DIC. An undiagnosed placenta accreta was found and a B-Lynch compression suture applied, achieving haemostasis. Cell salvage was unusable due to contamination.

After 2 hours of normalising parameters, she was successfully extubated on the critical care unit.

Her final Hb was 5g/L, having lost an estimated 60% of her blood volume. With erythropoietin & intravenous iron, she returned to an Hb of 10g/L, 5 weeks later.

In a situation which Obstetric Anaesthetists dread, with few avenues of escape, our conviction is that the use of Ketamine to induce & maintain intraoperative anaesthesia contributed to this patient’s survival. She was close to death and would not have tolerated added insult; yet few Western anaesthetists are familiar enough with Ketamine to do this, even in out-of-hospital practice. As anaesthesia is affluent countries becomes increasingly complex, this case reminds us that we have valuable lessons to learn from our colleagues in RPCs. After consultation within our Trust, we have written a protocol for full Ketamine anaesthesia, available for use throughout the hospital.

SOAP 2018