Obstetrical Crisis Management What is your Plan B? Brian J Kasson CRNA MHS Faculty/Clinical Instructor Nurse Anesthesia Program Northern Kentucky University Staff Nurse Anesthetist The Christ Hospital Cincinnati, OH Copyright 2016. Brian Kasson. All Rights Reserved
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Obstetrical Crisis Management...Obstetrical Hemorrhage – Best Clinical Practice n Hemorrhage cart n Hemorrhage meds –immediate access n Response team n Transfusion protocol n Unit
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Obstetrical Crisis ManagementWhat is your Plan B?
Brian J Kasson CRNA MHSFaculty/Clinical InstructorNurse Anesthesia Program Northern Kentucky UniversityStaff Nurse AnesthetistThe Christ HospitalCincinnati, OH
Copyright 2016. Brian Kasson. All Rights Reserved
Conflict of Interest Disclosure Statement
I have no financial relationships with any commercial interest related to the content of this activity.
I will discuss the following off-label use during my presentation:• Fentanyl• Bupivacaine• Atropine• Ondansetron• Ketorolac
Post Partum Hemorrhage
n Early cumulative EBL > 1000 ml
n OR - loss associated with s/sx of hypovolemia
Case reviews:
Denial and delay
Obstet Gynecol 2015;125:938-47
Anesth Analg 2015;121:142-8
Obstetrical Hemorrhage –Best Clinical Practice
n Hemorrhage cartn Hemorrhage meds – immediate accessn Response teamn Transfusion protocoln Unit based drills
Recognition and preventionAssessment of risk
Precise measurement of EBLActive management of 3rd stage by OB
n Use adjuvants – Fentanyl/Epinephrinen Attempt to Rx with ↑ volumen Replace/Resite
Do not waste time convincing yourself a block exists when it is inadequate!
Communicate with LDRN and OB!
EPI Volume Matters (a lot)
Bup 20 mg 4 ml 0.5%n=19
10 ml 0.2%n=19
20 ml 0.1%n=20
Pain (VAS) 4.37 0.88 0.25
Mean duration 43 min 100 min 120 min
Motor block + +++ +++
Complete relief 5.26% 57.8% 75%
Reg Anes Pain Med 1998;23(2):134-141
Converting labor EPI to C/S EPI
Converting a labor EPI to a C/S EPI
n Lido 2% 1:200,000 epinephrinen +/- Bicarb 1 meq/10 mln In the presence of a well functioning epidural-
10-15ml – in divided doses
IJOA 2012;21:294-309
Factors Thought to be Associated with Epidural Conversion Failure
n Duration of labor analgesian Tall v short staturen CSE v EPI onlyn OB specialist v non-specialistn Number of boluses for breakthrough painn Urgency of CS