ECG II

Fig. 18.1

Observed EKG in obstetrics operating theater

A parturient, gravida 7 para 6 at 38 weeks gestation, was placed under general anesthesia for an emergent C-section secondary to fetal bradycardia (Category III fetal heart rate tracings).

The anesthesiologist who performed the induction briefs you that a rapid sequence induction included cricoid pressure, 100 μg of fentanyl, 120 mg of propofol, and 100 mg of succinylcholine administered intravenously. A grade I view of the airway was obtained with laryngoscopy and a #7 oral endotracheal tube placed without difficulty. Initially, ETCO₂ was positive and auscultation of the lungs revealed bilateral breath sounds.

Preinduction vital signs were SpO₂ 100%, pulse 88, BP 110/56, temp 36.6, and weight 55 kg.

1.

How would you describe this arrhythmia?
2.

In general, what are the potential causes of this arrhythmia in parturients?
3.

What are the common causes and prevalence of maternal cardiac arrest?
4.

What are your next steps in managing this case?
5.

What laboratory tests would you order to help in your management?
6.

When should perimortem C-section start?

An OR team member identifies an empty 250 mL bag of 0.25% ropivacaine and 2 μg of fentanyl per mL. With more investigation, the team realizes that this bag was accidentally brought into the OR and administered as “antibiotics.”

7.

Knowing this information how would you manage the case?
8.

Which medications would you avoid in treating this disorder?
9.

Is there an upper limit to the amount of medicine/treatment that you would give in this situation?

Answers

1.

If the EKG leads are attached and accurate, this is cardiac arrest presenting as pulseless fine ventricular fibrillation.
2.

In 2015, the American Heart Association released its first statement regarding maternal cardiac arrest. In that statement they listed common etiologies of maternal arrest and mortality. This list is a mnemonic of the letters A through H, most of which are listed below.

Anesthetic complications – (neura xial, hypoxia, hypotension) and accidents/trauma (trauma and suicide)

Bleeding—coagulopathy, placental causes, uterine atony and/or rupture, surgical causes

Cardiovascular causes—myocardial infarction, cardiomyopathy, pulmonary hypertension, valvular disease, aortic dissection

Drugs—oxytocin, magnesium, drug error (local anesthetic), illicit drugs, opioids, insulin, and anaphylaxis

*Note that many anesthetic drugs may cause prolonging of the QT interval (volatile anesthetic agents, ondansetron, antibiotics such as ciprofloxacin, erythromycin, etc.) which may result in ventricular fibrillation.

Embolic causes—pulmonary embolism, amniotic fluid embolism, cerebrovascular event

Fever—sepsis and infections

General—Hs and Ts (hypoxemia, hypovolemia, hypo-/hyperkalemia, hydrogen ion (acidosis), hypothermia, tension PTX, tamponade—cardiac, toxins, thrombosis—coronary, thrombosis, pulmonary)

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