ultrasound in critical obstetric situations: the role of the anesthesiologist yaacov gozal, m.d....
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Ultrasound in Critical Obstetric Ultrasound in Critical Obstetric Situations: the Role of the Situations: the Role of the
AnesthesiologistAnesthesiologist
Yaacov Gozal, M.D.Associate Professor of AnesthesiologyHebrew University and Hadassah Medical SchoolChair, Dept. of AnesthesiologyShaare Zedek Medical CenterJerusalem
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INTRODUCTIONINTRODUCTION
Anesthesiologists: key role in high risk pregnancies
Member of a multidisciplinary team
ICU: 2-4/1000 deliveries
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INTRODUCTIONINTRODUCTIONTraditionally: background of previous
excellent health and large physiological reserve
Modern maternal characteristics:◦Increasing age◦Morbid obesity◦Congenital and acquired cardiac disease◦Assisted reproduction
Diagnostic dilemmas
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INTRODUCTIONINTRODUCTION
Emergencies: quick and accurate diagnostic tools
Ultrasound: ◦Safe and easily accessible◦Ease of use◦Connectivity and data storage◦Reduced size and weight
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UltrasoundUltrasoundRoutine locations:
◦Emergency Room◦Delivery room◦Operating Room◦PACU◦ICU
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EchocardiographyEchocardiographyProvides volumetric and flow
dataShows the functioning heartOB patient is the ideal subject:
◦Ant and left displacement of heart◦Elevated diaphragm
Class I recommendation according to American, British and European guidelines
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The FATE ExaminationThe FATE Examination
Jensen MB et al, Eur J Anaesthesiol 2004; 21:700-707
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The FATE ExaminationThe FATE ExaminationNormal Subcostal 4-Chamber ViewNormal Subcostal 4-Chamber View
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The FATE ExaminationThe FATE ExaminationNormal Apical 4-Chamber ViewNormal Apical 4-Chamber View
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The FATE ExaminationThe FATE ExaminationParasternal Long AxParasternal Long Axisis
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The FATE ExaminationThe FATE ExaminationParasternal LV Short AxisParasternal LV Short Axis
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LUNG ULTRASOUNDLUNG ULTRASOUNDAcute respiratory failure: one of
the most distressing situationsPhysical exam. and chest X-Ray:
imperfectNeed for sophisticated tests and
delay managementLung U/S: standard tool in
critical care
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LUNG ULTRASOUNDLUNG ULTRASOUNDBLUE-ProtocolBLUE-Protocol
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LUNG ULTRASOUNDLUNG ULTRASOUNDBLUE-ProtocolBLUE-Protocol
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LUNG ULTRASOUNDLUNG ULTRASOUNDNormal LungNormal Lung
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LUNG ULTRASOUNDLUNG ULTRASOUNDNormal LungNormal Lung
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Postpartum HypotensionPostpartum Hypotension29-yr old primaparousNo significant medical historyUncomplicated CS, with minimal
blood loss under spinal anesthesia at 35 weeks’ gestation
6 hrs after delivery: Hypotension Tachycardia Febrile Hb: 12
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Postpartum HypotensionPostpartum Hypotension
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Postpartum HypotensionPostpartum HypotensionHypotension due to cardiac failureDagnostic: postpartum
cardiomyopathyNo signs of IHD (ECG, chest pain,..)Treatment:
◦Inotropic support◦Diuresis◦ACE inhibitors
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Anaphylactic ShockAnaphylactic Shock35-yr old primaparousNo significant medical historyDelivery suite: epidural analgesia and
urinary catheterNo progress CSBaby delivered: hemodynamic
collapse intubation, fluids,
vasopressors
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Anaphylactic ShockAnaphylactic Shock
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Anaphylactic ShockAnaphylactic Shock
Adrenaline bolusesSteroidsH1 and H2 blockersAdrenaline continuous infusion Removal of the urine catheter
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Amniotic Fluid EmbolismAmniotic Fluid Embolism
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Amniotic Fluid EmbolismAmniotic Fluid Embolism
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Amniotic Fluid EmbolismAmniotic Fluid Embolism
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Amniotic Fluid EmbolismAmniotic Fluid EmbolismDIC: TEG flatThrombocytopeniaSupportive treatment
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Pulmonary EmbolusPulmonary Embolus35-yr old, Gravida 5, Para 3Vaginal delivery at 40
weeks’gestationPostpartum hemorrhageAtonic uterus: pitocin, metherginSevere bleeding: 10 units RBC
and 10 units FFPDuring surgery, SaO2: 70%Hemodynamic instability
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Pulmonary EmbolusPulmonary Embolus
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Pulmonary EmbolusPulmonary Embolus
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Pulmonary EmbolusPulmonary Embolus
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LUNG ULTRASOUNDLUNG ULTRASOUNDPneumothoraxPneumothorax
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LUNG ULTRASOUNDLUNG ULTRASOUNDPneumothoraxPneumothorax
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LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea
40-yrs old, gravida 3, para 2Acute respiratory distress at 31
weeks’ gestationMedical background: asthma,
morbid obesity and diabetesExamination:
◦Tachypneic◦SaO2: 85% (RA)◦Bilateral wheezing◦Lower limb edema
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LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea
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LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea
B-Lines
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TTETTEAcute DyspneaAcute Dyspnea
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LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea
Diagnosis: acute pulmonary edema rather than exacerbation of asthma
Management: diuretics and oxygen therapy
Rapid Improvement
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CONCLUSIONSCONCLUSIONSUltrasound: unique toolDiagnostic and monitoring
capabilities
Ultrasound=
3rd eye of the anesthesiologist