Verna Thomas, BSN, SRNAVerna Thomas, BSN, SRNA

Myometrial Injection of Vasopressin

Myometrial Injection of Vasopressin

ObjectivesObjectives

• Familiarize learner with myomectomy procedure and management options

• Describe anesthetic considerations for myomectomy• Identify purpose for use of vasopressin and mechanism of

action• Recognize potential complications associated with use of

vasopressin • Engage the learner in a spirited discussion regarding a

case of myometrial vasopressin injection

• Familiarize learner with myomectomy procedure and management options

• Describe anesthetic considerations for myomectomy• Identify purpose for use of vasopressin and mechanism of

action• Recognize potential complications associated with use of

vasopressin • Engage the learner in a spirited discussion regarding a

case of myometrial vasopressin injection

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Case of Interest• 29 y/o AA Female, • 67 kg• ASA 2, MP II• Employed RN• History of uterine fibroid, syncope at work,

received cardiac work-up, anemic• Robotic Assisted Laparoscopic

Myomectomy

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MyomectomyMyomectomy• Define most common benign tumor of the uterus in women of reproductive age

• Prevalence clinically diagnosed in 25% of women with a predicted incidence of 75%

• Rationale myomectomy versus hysterectomy to preserve fertility

• Population predominance amongst African American women of child-bearing age to ~

50y

• Define most common benign tumor of the uterus in women of reproductive age

• Prevalence clinically diagnosed in 25% of women with a predicted incidence of 75%

• Rationale myomectomy versus hysterectomy to preserve fertility

• Population predominance amongst African American women of child-bearing age to ~

50y

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Management OptionsManagement Options

• Uterine Artery Embolization• Uterine Artery Embolization

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Management OptionsManagement Options

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• Laparoscopic Assisted Abdominal Myomectomy (LAAM)• Laparoscopic Myomectomy (Standard)

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• Laparoscopic Assisted Abdominal Myomectomy (LAAM)• Laparoscopic Myomectomy (Standard)

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Robot AssistedRobot Assisted

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Anesthesia ConsiderationsAnesthesia Considerations

• Bleeding• Hemodynamic Alteration• Respiratory Compromise• Positioning

• Bleeding• Hemodynamic Alteration• Respiratory Compromise• Positioning

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Myoma Blood SupplyMyoma Blood Supply

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Case Update #1• Standard Induction• Trocars/Insufflation• Vasopressin Injection• Re-insufflation

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Traditional UseTraditional Use

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Endogenous SynthesisEndogenous Synthesis

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EffectsEffects

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Synthetic Vasopressin in Myomectomy

Synthetic Vasopressin in Myomectomy

• Control bleeding• Potent vasoconstrictor• 20U/ml diluted in 100-200ml of NSS• Max injection 3-5U• Anesthesia should be notified before

injection• Aspirate before injection• 15-25 min half-life

• Control bleeding• Potent vasoconstrictor• 20U/ml diluted in 100-200ml of NSS• Max injection 3-5U• Anesthesia should be notified before

injection• Aspirate before injection• 15-25 min half-life

Medical Templates 2003Medical Templates 2003

Template 8Template 820 units in 200ml NS

Max 3-5 units

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Case Update #2• Robotic Assisted Laparoscopic

Myomectomy• Approximately 45-60 min into the case• Incision through serosa• BP cuff cycling every 3 minutes

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Series of Unfortunate EventsSeries of Unfortunate Events

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Differential DiagnosisDifferential Diagnosis• Venous Air Embolism (VAE)

– Subatmospheric pressure w/i an open vein– Decreased EtCO2, desaturation, sudden hypotension– TEE, precordial Doppler sonography

• Pulmonary Embolus– Entry of blood clots, fat, tumor cells, air, amniotic fluid, or

foreign material into venous system– sudden cardiovascular collapse, hypoxemia, bronchospasm,

decreased ETCO2, elevated CVP and PAP – TEE; may not reveal the embolus but will show R. heart

distension and dysfunction

• MI– No preoperative comorbidities– HoTN, bradycardia, no detectable ECG changes– TEE; more sensitive indicator of MI than ECG

• Hemorrhage

• Venous Air Embolism (VAE)– Subatmospheric pressure w/i an open vein– Decreased EtCO2, desaturation, sudden hypotension– TEE, precordial Doppler sonography

• Pulmonary Embolus– Entry of blood clots, fat, tumor cells, air, amniotic fluid, or

foreign material into venous system– sudden cardiovascular collapse, hypoxemia, bronchospasm,

decreased ETCO2, elevated CVP and PAP – TEE; may not reveal the embolus but will show R. heart

distension and dysfunction

• MI– No preoperative comorbidities– HoTN, bradycardia, no detectable ECG changes– TEE; more sensitive indicator of MI than ECG

• Hemorrhage

*

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Transesophageal Echocardiogram

Akinesis

Transesophageal Echocardiogram

Akinesis

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Transesophageal Echocardiogram

Normal

Transesophageal Echocardiogram

Normal

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Case Update #3• Weak/thready carotid pulse• Absent radial pulses• PEA w/ACLS• Central line placement• Swan ganz placement• Milrinone and Epinepherine infusion• Pulmonary Edema• Lasix • Refractory hypoxemia

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Case ConclusionCase Conclusion

• Prepped for ECMO• Heparinized• Near Complete Resolution• Balloon Pump• Following Commands• Pressors and balloon pump

discontinued• Discharged from hospital POD 8

• Prepped for ECMO• Heparinized• Near Complete Resolution• Balloon Pump• Following Commands• Pressors and balloon pump

discontinued• Discharged from hospital POD 8

What Did We Learn

Vigilance• Never deviate from standard of care• Treated the BP• Notified the surgeon and called for help• Rapid assessment and

treatment/supportive care

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Questions/CommentsQuestions/Comments