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Is this the oral boards? Anesthetic management for cesarean delivery in a patient with h/o IV drug use, active endocarditis with severe tricuspid regurgitation and preeclampsia with severe features.
Abstract Number: RF7A10-504
Abstract Type: Case Report Case Series
37 year old G5P3013 at 22w5d GA with a history of IV drug use including heroin and meth, presented from an outside hospital for sepsis and a newly diagnosed pregnancy. On initial evaluation found to have tricuspid valve MSSA endocarditis, bacteremia, and septic emboli to the lungs and kidneys. TTE on admission was significant for severe tricuspid regurgitation and tricuspid septal leaflet vegetation. Initial management included IV antibiotics for the endocarditis and buprenorphine for the IVDU. Over the next three weeks her course was complicated by persistent tachycardia, gestational diabetes, recurrent fevers with positive blood cultures, line associated VTE, worsening tricuspid regurgitation and preeclampsia with severe features with elevated LFTs. At 26w4d GA the decision was made to proceed with cesarean delivery (CD) for breech presentation and worsening preeclampsia with severe features.
In the OR, a pre-induction arterial line was placed for hemodynamic monitoring followed by a CSE. The IT dose was 7.5 mg hyperbaric bupivacaine, 500 mcg PF morphine and 25 mcg fentanyl. After positioning and hemodynamic stability achieved with a phenylephrine infusion, the epidural was incrementally dosed with an additional 10 mL of 0.5% bupivacaine. 15 minutes after dosing the epidural, assessment of the block was determined to be inadequate for surgery. An additional 10 mL of 3% Chloroprocaine was given via the epidural, however 10 minutes later the block was still inadequate for surgery. Due to the inadequate surgical block and patient anxiety it was decided to convert to general anesthesia.
Rapid sequence induction with etomidate, ketamine and succinylcholine and tracheal intubation were uncomplicated. During the CD a continued phenylephrine infusion was required for hypotension and sinus tachycardia was persistently in the 140s. Quadratus lumborum blocks were performed for post-operative analgesia prior to emergence and extubation. The patient was transported to the surgical ICU for post-operative monitoring. In the ICU the patient continued to have a vasopressor requirement after resolution of spinal and epidural complicated by low urine output. Dobutamine was started for inotropic support, the patient quickly responded with diuresis and resolution of vasopressor requirement within eight hours. Postpartum pain management was adequately achieved with scheduled acetaminophen, NSAIDs, gabapentin and buprenorphine.
This case presented challenges in antepartum optimization as well as peripartum anesthetic management. A slow neuraxial anesthetic was preferred, however the IT bupivacaine and subsequent epidural dosing were inadequate for surgical anesthesia. It is possible the patient had hyperalgesia due to her IVDU, but this highlights the need for back-up plans given not only the co-morbidities of this particular patient but the frequent drug shortages we currently face.