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Intramuscular Ketamine in an Acutely Psychotic Parturient
Abstract Number: RF2BB-274
Abstract Type: Case Report Case Series
Introduction: More women with psychotic disorders are having children and these pregnancies are at higher risk than the average parturient. There is an even greater compromise on both mother and baby’s health when a manic or psychotic episode complicates the intrapartum period. This case presents unique ethical and medical challenges to anesthesiologists, obstetricians, and hospital administrative teams of an acute psychotic parturient.
Case: A 32 y/o G1P0 at 38 weeks with PMH of bipolar disorder and no prenatal care presented to labor and delivery from jail with oligohydraminos in the setting of premature rupture of membranes. On exam, she was agitated, physically abusive to staff and uncooperative, refusing any treatment including fetal heart monitoring, pelvic exam, vital signs, and IV access. It was evident that she was experiencing an acute psychotic episode. As she would not be able to safely tolerate labor, the obstetricians decided to perform an urgent C/S. Medical ethics was consulted due to the critically endangered fetus and declared that she lacked capacity to make an informed decision regarding her medical care. Given her state of uncontrolled agitation, it was evident that regional anesthesia was not a feasible option for her and the plan was to proceed with general anesthesia. With the assistance of police, two 150mg Intramuscular (IM) ketamine injections in each deltoid muscle were administered. The patient was then rushed to the operating room on a stretcher and an IV was placed. She was induced with propofol and succinylcholine, ET was placed and patient underwent an unremarkable caesarean section. On emergence, 5mg of haloperidol and 50 mg of diphenhydramine were administered intramuscularly for further anxiolysis. Despite her prolonged emergence from general anesthesia of 45 mins, she was successfully extubated in the OR and was transported to the recovery room. Her post-partum care involved the psychiatry team and she was discharged on POD4.
Discussion: Alterations in hormone level and the physiological demands of pregnancy can temporally unmask subclinical disease in patients with a psychiatric history. Psychotic parturient are at higher risk of having challenging labor and complications including adverse obstetric and neonatal outcomes. This case looked at the management of a parturient with acute psychotic episode which required emergency cesarean delivery. Due to her mental state, regional anesthesia, rapid sequence induction, and intravenous induction was not possible. Ketamine has been used as a sole anesthetic due to its minimal neonatal depression. In rare cases, it has been associated with intraoperative awareness, and for this reason, intravenous and inhalational agents were supplemented.
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