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10/23/2014October 23, 2014UCSFOB/GYN Update:What Does theEvidence Tell Us?Mark Rollins, MD, PhDUCSF Director Obstetric h/maternalinfanthealth/pmss.htmlDiscussion of ACLSconsiderations in pregnancy Frequency of Cardiac Mortality ACLS Code Modifications Local Anesthetic Toxicity Perimortem Delivery Checklists & Simulation1

ternalinfanthealth/pmss.htmlCauses of pregnancy-related death in the United States: 2006–2010Anesthesiology, June 2014Anesthesiology, June 2014Part 12: Cardiac Arrest in Special Situations: 2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular CareTerry L. Vanden Hoek, Laurie J. Morrison, Michael Shuster, Michael Donnino, Elizabeth Sinz,Eric J. Lavonas, Farida M. Jeejeebhoy and Andrea GabrielliCardiac Arrest: 1 in 7,151(CI 1:5,319 - 1:9,615)2

10/23/2014Cardiac arrest in pregnancy Incidence:1:20,000 patients Mostly: stick toACLS algorithms IV abovediaphragm Difficult airway Left uterinedisplacement Cesarean sectionKey Objectives Appropriate Team Relieve Aorto-Caval CompressionAnesth & Analg, June 2014 How Does This Consensus StatementDiffer From Existing Guidelines?Call for Help“Code OB” Focus on Chest Compressions Do Not Delay Defibrillation Prepare for Emergent Delivery Checklists and Simulation3

10/23/2014Call for HelpCardiology, Anesthesia, Obstetricians & Nurses:“Hey, Who’s resuscitatingthe baby?”The phenylephrine is causing the decels Should we stop the nitro drip?Can you use that pressor?Why are you tilting her to the left?The loss of variability is just the fentanyl Are you sure you want a stent placed?You won’t be able to place an epidural for delivery I thought Versed was a teratogen Isn’t supplemental oxygen bad for the baby?Where did all this fluid come from?Slide by Elizabeth WhitlockAortocaval compressionLeft uterine tilt/displacement The gravid uterus compresses theIVC and aorta when supine Hypovolemic shockKerr MG: Cardiovascular dynamics in pregnancy and labor. BMJ Bull 24:19, 1968.Slide by Elizabeth WhitlockSlide by Elizabeth WhitlockVanden Hoek. Circulation; 122:S829. 20104

10/23/2014Left uterine tilt/displacementDisplace!Lift!Slide by Elizabeth WhitlockVanden Hoek. Circulation; 122:S829. 2010Cardiac arrest in pregnancy: CABDE C: Circulation Left uterine displacement Compressions An example of a“simplified algorithm”2 or 3 cm Higher on Sternum5-cm depth (Hard)100/min (Fast)Rotate Compressors q 2 minMinimize InterruptionsCapnography ( 10 mmHg) IV above the diaphragmAirway and Breathing Call for Help Don’t get fixated onETT placementF.M. Jeejeebhoy et al. / Resuscitation 82 (2011) 801–809Slide by Elizabeth Whitlock5

10/23/2014Airway and BreathingCardiac arrest in pregnancy: CABDE D: Defibrillate: 10 breaths per min. 500-700 ml/breath EtCO2 confirmation Performed on shockablerhythms ASAP No change in energy duringpregnancy AED? Goal of 3 min from collapse Removal of monitorsSlide by Elizabeth WhitlockCardiac arrest in pregnancy: CABDE D: Drugs: All ACLS drugs OK Oxytocin? Lipid Emulsion withLocal Anesthetic ToxicityPerioral Numbness or TinglingMetallic TasteTinnitus DiplopiaLightheadednessConfusion & DrowsinessRestlessnessSense of Impending DoomMuscular TwitchingTonic-Clonic SeizuresUnconsciousnessRespiratory Arrest6

10/23/2014Tachycardia Advanced AgeHypertensionMyocardial DepressionDecreased Cardiac Output Severe Cardiac Dysfunction Conduction AbnormalitiesPeripheral VasodilationHypotensionConduction BlockSinus BradycardiaVentricular ArrhythmiasAsystole CollapseNeal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8 Liver Disease Low Plasma Protein AcidosisNeal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8Neal JM, et al. Reg Anesth Pain Med. (2012) 37:16-87

10/23/2014Anesth Analg. February 2013Neal JM, et al. Reg Anesth Pain Med. (2012) 37:16-8Anesth Analg. April 20128

10/23/2014Cardiac arrest in pregnancy: CABDEBMJ. December 2003 E: Extract (the fetus) Incision at 4 minutes Delivery by 5 minutespost-arrestSlide by Elizabeth WhitlockPerimortem cesarean sectionPerimortem cesarean sectionNo perfusing rhythm after 4 minutes?American Journal of Obstetrics and Gynecology (2005) 192, 1916–219

10/23/2014Perimortem cesarean sectionAmerican Journal of Obstetrics and Gynecology (2005) 192, 1916–21Perimortem cesarean sectionAmerican Journal of Obstetrics and Gynecology (2005) 192, 1916–21Perimortem cesarean section Location? Operative Vaginal Delivery?10

10/23/2014AJOG; 203:179.41-5. 2010Anesth & Analg. 118(5):1003Anesth & Analg. 118(5):100311

EMERGENCY MANUALCOGNITIVE AIDS FOR OBPERIOPERATIVE CRITICAL EVENTSCHECKLISTS10/23/2014Adapted from: Stanford Anesthesia Cognitive Aid Group’s Emergency Manual 2014, V2.0 and Gawande et al. OR Crisis Checklists NEJM 2013; 368: 246-53.ACLSAsystole/PEA . .1Bradycardia – Unstable . .2Tachycardia – Unstable . .3Pulseless VF/VT . 4CRITICAL EVENTS: NON-ACLSAmniotic Fluid Embolism . .5Anaphylaxis . 6Bronchospasm . . .7Difficult airway – Unanticipated . .8Fire . . .9Post-partum Hemorrhage . . .10Hypotension . .11Hypoxia . . .12Local Anesthetic Toxicity . . .13Malignant Hyperthermia 14Myocardial Ischemia .15Tachycardia – Stable SVT . .16Total Spinal Anesthesia . .17Transfusion Reaction . .18Venous Air Embolus .19Adapted from: Stanford Anesthesia Cognitive Aid Group’s Emergency Manual 2014, V2.0 and Gawande et al. OR Crisis Checklists NEJM 2013; 368: 246-53.Are you seeking to help clinicians deliver the best possible care during medicalemergencies?Despite best intentions, well-trained clinicians often miss known key steps duringcritical events.This FREE perioperative Emergency Manual contains 25 critical events as well asCrisis Resource Management key points. It has been iteratively tested with simulationover many years.Table of ContentsMobile DownloadPermissions & Local CustomizationAppropriate CitationDisclaimer12

10/23/2014Potential Drills & SimulationsSevere Fetal BradycardiaOpportunities for New FacilitiesWhere are the supplies located? Airway cart? Code cart?Eclamptic SeizureWhat are the work flows?Shoulder DystociaHow long does it take to transfer patient locations?Massive HemorrhageHow do I call for help? A code? A crash?Failed IntubationHow do I get emergency blood?AnaphylaxisHow do I get STAT labs? Point of care testing?Total SpinalMagnesium OverdosePreston P, et al. Seminars in Perinatology 2011. 35:84 Cardiac Arrest in Pregnancy is Rare Appropriate Help “Code OB” Relieve Aorto-Caval Compression Focus on Compression & Defibrillation Use Lipid Emulsion with LAST Prepare Early for Emergent Delivery Checklists and Simulation Beneficial13