Charles D Giordano CRNA, MSN (Major USAFR)

My Background
 One of the first few cadre’s of CRNA’s trained at University of
Pittsburgh Nurse Anesthesia Program to be “allowed” to perform
anesthetics on parturient patients beginning in 2006
 2+ years of independent practice as a CRNA
 -The Birthplace at Faxton St. Lukes Hospital in Utica NY
 -2000+ deliveries a year 24 hr in house call 2011-current
 2 years as the only full time OB/CRNA at Magee Womens
Hospital of UPMC
 -10,000+ deliveries a year
 -Involved in hands on and didactic instruction for the
UOPNAP and clinical reorientation to OB for seasoned
CRNA’s in the system
My Background
 2nd Generation OB/CRNA
 Following in the footsteps of Charles A Giordano
 40+ years of experience

 Overall good guy

 Management of Emergencies
 14 combined years of Active Duty and Reserve Military experience
 STICU, C4, TNCC, SAMMC
 Deployed FST Philippines 2010 sole anesthesia provider for area
 Philippine casualties

 Austere environment

 UPMC
 Call team, OB
 Cultivation of “6th Sense” follow your gut!
Giulianna S.
Giordano 8/9/2010
31 weeks
Partial Abruption
Missed her birth by 1.5hrs
Objectives
 Understanding of Common OB emergencies and
Anesthetic Implications for each
 Ante-partum (before)
 Intra-partum (during)
 Post-partum (after)
Physiologic Changes of Pregnancy
 CNS -  MAC and LA requirements, lumbar lordosis, 
spread
 Resp – Compensated Respiratory Alkalosis
  (MV, alveolar ventilation, TV, O2 consumption, RR, IC) ,  (TLC,
FRC)
 CVS -  (HR, CO, SV, uterine blood flow)  (SVR, PVR,
MAP),  volumes,  pressures
 GI -  gastric reflux and acidity,  gastric motility and
emptying
 Renal -  (GFR, renal blood flow, Cr clearance,
aldosterone, bicarb excretion)  (BUN, Cr)
Common Anesthetic Techniques
 Spinal Anesthesia (% block)
 Itrathecal placement of local anesthetics for
 C/S
 1.4-2 cc 0.75% bupivicane with dextrose with narcotics

 Dextrose baricity and confirmation

 Lidocaine is still used at some facilities

 Surgical Level achieved below T4 is the goal

 Late stage I and stage II labor

 Fentanyl 20-25mcs with 0.2-.5cc 0.75% Bupivicane

 Or 1cc 0.25% Bupivicane

 Pain relief for approximately 1-2 hours

 Controversial decrease in FHT, High Spinal

Spinal
 Spinal Con’t
 Saddle block for Circlage
 1 CC 0.75% Bupivicaine +/- fentanyl
 Keep seated for 2-5 minuets
 Post partum repair of vaginal tear/episiotomy
 1st degree - vaginal mucosa and perineal skin
 2nd degree – subcutaneous tissue
 3rd – through rectum
 4th – into rectal mucosa
 All can be cause of blood loss
Spinal
 Complications:
 Surgical Level not achieved = GA
 High Spinal
 Intubation
 Support vs
 C/S
 PDPH 1.5-11% incidence 14% closed claims
 More than 1 attempt

 Size/shape of needle
Common Anesthetic Techniques
 Epidural Analgesia with placement of epidural
catheter (volume block)
 Placement of local anesthetic in the epidural space
Epidural
Common sites of placement L2-3 to L4-5
 Common dosing
 Bupivicane 0.0625-0.125% infusion with 2mcs/cc fentanyl
(cardiotoxic low concentrations safe)
 Ropivicane 0.08-0.2% infusion with fentanyl (expensive)
 Bolusing for BT pain
 Lidocaine 1-2% w/-w/o epinephrine 5-8cc
 Shorter acting, stronger block, quicker onset

 Bupivicane 0.625-0.25% 5-8cc

 Longer acting, more diffuse block, longer onset

 Fentanyl 50-100 mcs q 4-6 hours

 High doses associated with maternal side effects, fetal
depression, pruritus
Epidural
 For C/S
 Establish that the epidural is working
 Has it been turned down
 Last bolus
 Mom’s mental state
 Dosing for C/S
 2% Lidocaine with 1:200,000 epinephrine
 10-20cc +/- 100mcs of fentanyl
 Moderate onset
 1.5-3 hours duration
 3% Chloropricane 10-20cc
 Quicker onset
 45min to 1hr duration
 Duramorph (PF Morphine) for post op pain
 2.5- 5mg in last 1/3rd of C/S
 Onset 30-60 min duration 16-24hrs
 Delayed Respiratory Depression 6-12 hours later
 Crosses into CSF acts centrally
Epidural
 For Post-partum period:
 Laceration
 Manual extraction of Placenta
 Surgical extraction of Placenta
 Tubal Ligation
 Early fetal demise
 Retained products of conception
 May need adjuncts
Epidural
 Complications
 Failed regional
 Spinal vs GA
 Vascular insertion
 SA insertion
 High Block
 Epidural PDPH – 52% after “Wet Tap” 1-2% W/O
 Epidural Hematoma
S & S of Local Toxicity
 Circumoral numbness
 Ringing in the ears
 Seizures
 Cardiac arrythmias
 Hypotention

www.lipidrescue.com
Lipid Rescue for Local Toxicity
Get Help !

 Initial Focus
 Airway management: ventilate with 100% oxygen (BLS/ACLS and ABC’s)
 Seizure suppression: benzodiazepines are preferred
 Basic and Advanced Cardiac Life Support (BLS/ACLS) may require prolonged effort

 Infuse 20% Lipid Emulsion (values in parenthesis are for a 70 kg patient)

 Bolus 1.5 mL/kg (lean body mass) intravenously over 1 min (~100 mL)
 Continuous infusion at 0.25 mL/kg/min (~18 mL/min; adjust by roller clamp)

 Repeat bolus once or twice for persistent cardiovascular collapse

 Double the infusion rate to 0.5 mL/kg per minute if blood pressure remains low
 Continue infusion for at least 10 mins after attaining circulatory stability
 Recommended upper limit: approximately 10-12 mL/kg lipid emulsion over the first 30
mins
Lipid Rescue Cont.
 Avoid vasopressin, calcium channel blockers, β-
blockers, or local anesthetic
 Avoid high dose epinephrine; preferrably use doses < 1
mcg/kg
 Alert the nearest facility having cardiopulmonary
bypass capability (esp for local anesthetic toxicity)
 Avoid propofol in patients with cardiovascular
instability
Epidural Blood Patch
 10-20 cc autologous blood inserted into the epidural space to
decrease PDPH
 Epidural space found
 Blood drawn in a sterile fashion
 Inject in epidural space until patient is uncomfortable or 20cc
 May be done up to three times
 Consider neurology consult with second attempt
 Conservative measures until 48-72 hours post-puncture
 Caffeine
 Hydration
 Immobility
 Smokers
 NSAIDS and tylenol
Back Pain
 A 9lb fetus having been forcibly expelled into the
world through a 8lb pelvis has been known to cause
back pain and transient neuropathy
 That being said:
 S/S of infection?
 Persistent pain and neuropathy?
 Any question of epidural hematoma?
 Co-morbidities = bleeding
 Check it out!
Anesthetic Techniques
 General Anesthesia – the last resort
 Airway Airway Airway
 Body Habitus –
 large tongue

 redundant oropharyngeal tissue

 Friability of tissue

 Inability to align airway axis

 Decrease in FRC

 Full stomach

 Fetal Depression
 Maternal Bonding
 Yikes!
If your
facility does
not have a
Glidescope
than you
need to get
one!
 Difficult Airway
Cart/FOB
Ante-Partum
 PIH/Chronis HTN
 Pre-Eclampsia/Eclampsia
 HELLP Syndrome
 Partial Abruption
 The Acreta’s
 GDM/DM
 LGA/IUGR/Pelvic Incompatability
PIH vs Chronic HTN
 Chronic
 Prior to 20 wks
 Multiparity, DM, Obesity, Race, Age
 More likely to have Pre-E
 Most do well can have exacerbations
 PIH
 After 20 wks
 Can be precursor of Pre-E/Eclampsia
 Initiate lab work to rule out
 Proteinuria, Platelets LFT’s

Pre-eclampsia
 Criteria: HTN, edema, proteinuria, onset > 20 wks
gestation
 6-8% incidence, types: mild + severe
 Eclampsia = preeclampsia with Sz +/- coma, Sz on
Mg2+  incidence of structural neurologic disease
 Associations: 1st pregnancy (primes) and multiparity,
obesity, extremes of age, chronic HTN +/- chronic
renal disease, abruption 6x more common
Pre-eclampsia
 Pathogenesis:  Renal: glomerular
vasoconstriction enlargement  proteinuria, 
(thromboxane production) > sensitivity to RAAS   AII
vasodilation (prostocyclin, sensitivity
nitric oxide production)
 Pathophysiology -  Heme: hypo-coaguability,
multisystem d/o thrombocytopenia (15-30%,
 Neuro - Sz, coma, visual 10%< 100 K, DIC)
disturbances, HA, hyper-  Placenta:  perfusion 
excitability, hyperreflexia,  IUGR, abruptio placentae
ICP (2%), fetal distress
 Resp -  colloid oncotic  Maternal Mortality: Sz,
pressure  pulm edema,
pharyngolaryngeal edema cerebral hemorrhage (most
 GI:  LFT’s, TA > 1000 IU/L, common), renal and hepatic
hepatic edema (expansion of failure, DIC, pulmonary
Glisson’s capsule) edema, placental abruption
Anesthetic Considerations
 Stabilize and deliver - MgSO4,  MgSO4 - initial bolus of 4-6
judicious use of fluid, anti gm, 1-2 gm/hr drip,
HTN agents, expectant therapeutic range of 4-8
management with timely mEq/l: 10 mEq/l = loss of
patellar reflexes, 12-16 = resp
delivery, no defasiculating arrest, 20 = asystole
dose  Tx of Mg toxicity - Calcium
 C/S for OB indications only Gluconate, CaCl, dialysis
 Observation for 24 hours  Mg mechanisms of action:
postpartum Central anticonvulsant
 Labor epidural and spinal not Inhibits Ca2+ pre and
contraindicated postsynaptically
 Labs - CBC, platelets, PT/PTT, Peripheral vasodilatation
fibrinogen q 4-6 hrs, Potentiates all muscle
electrolytes, Mg levels, LFT’s relaxants
Pre-eclampsia Treatment
 Hydralazine - 1 blocker: arteriole > venule dilatation, 
SVR with  HR and  CO
 Labetolol - 1:3 blocker: SVR with Mod Dec. HR and 
CO
 NTG - converted to nitric oxide  venous dilation + 
preload, use non-absorbent tubing
 NTP - converted to nitric oxide  both arterial + venous
dilatation:  SVR +  preload, initial dose of 0.5
mcg/kg/min, may cause maternal and fetal cyanide toxicity
 Nifedipine - slow channel Ca2+ blocker, works on arterial
+ arteriolar smooth muscle, vasodilatation > cardiac
effects, SE: facial flushing, HA, tachycardia
HELLP Syndrome
 H - hemolysis, hemolytic anemia, bilirubin > 1.2 mg/dl
 EL -  liver enzymes: SGOT > 70 U/l, LDH > 600 U/l
 LP - low platelets < 100 K
 S/S - malaise, RUQ or epigastric pain, N/V, viral like
syndrome
 HTN + Proteinuria may be absent
 Peak intensity 24-48 hrs postpartum
 Usually compensated DIC with normal coagulation
Regional with Low Platelets
 The $100 question
 Textbooks say 100k
 Studies inconclusive
 TEG if you have one
 Not gold standard not studied
 Anecdotal evidence good
 Pt/ptt/INR not indicators
 No TEG no regional
Partial
Abruption
Incomplete
separation of placenta
from uterine wall.
May cause bleeding
May be occult
Fetal Distress
Fetal
Hypovolemia
C/S possible
Volume
resuscitate mom
and baby
Placenta
Accreta/Increta/Percret
a
Penetration of the placenta
into the uterine myometrium
and beyond
Can be caught on US but not
always and severity questionable
Can cause
Bleeding
Uterine inversion

C/Hysterectomy
Be prepared for GA
Big IV’s
Blood in the room
Cell Saver/Salvage

True Life threatening

emergency if not recognized
early
Gestational DM/DM
 Most common pregnant  2nd half of pregnancy
medical condition  10-15% require insulin
 3-5% incidence  fasting blood glucose > 95-
 90% of all DM in pregnancy 105mg/dl
  with advanced maternal   in insulin dose (50-100%)
age above pre-pregnancy
 prone to type II-DM in later  Late pregnancy:  insulin due
years to  fetal glucose utilization
  insulin requirement in   maternal + fetal Cx
pregnancy  Check BS, Macrosomia
 Infant will need BS/early
feeds
LGA/UGR/Pelvic Incompatibility
 LGA = Large for gestational age = Big Baby
 Failure to progress
 Long labor
 Fetal distress, placental deterioration
 C/S – usually not acute
 US’s lie – not our call

 Pelvic Incompatibility
 Small pelvis + Big baby = C/S
 Choose your mate wisely
 Intrauterine Growth Retardation
 Variety of reasons, placental, nutritional, drugs/alcohol/smoking,
genetic anomalies
 Back of your head – this may not go well am I prepared for the worst
 Not normal causes of Stat C/S but can turn out that way
Intra-Partum or what goes wrong
in the middle of the night and I
have to go do stat/hurry up C/S
 Fetal distress
 Prolapsed cord
 Failure to decend
 Breech in labor
 Abruption
 Ruptured uterus
 C/Hysterectomy
 Chorio
 Placenta Previa
 Fetal Intolerance to Labor
 Its 1500 and I have a T-time/1700 I want to go home
Stat C/S
 Prolapsed cord
 Umbilical cord is between the baby’s head and across the cervical os
 Limited BF to fetus – downward dog to OR with triage nurse attatched
 Abruption
 Placenta actively tearing away from uterus
 Time is of the essence
 Mom can Bleed
 Baby can bleed = pale neonate
 Low FHT
 Normal FHT 110-150 bpm
 Deceleration < 110 for >30sec
 Sign of Fetal Distress
 Can Happen for all of these reasons
 If OB calls a STAT be prepared for GA
 May be called for a pattern = NRFHT
 Ask if there is time for regional
 Can resolve on their own
 LUD
 Oxygen
 Turn Pitocin off
 Terbutaline
 Hands and Knees
 Fetal Intolerance to Labor
 NRFHT
 Many reasons
 BF not getting to fetus
C/S continued
 Breech in Labor
 Breech birth considered very dangerous and can cause fetal distress – birth
trauma
 Footling breech – a foot or two leading the way out = stat/hurry up C/S
 May have time for regional
 Prepare for GA
 Placenta Previa
 Placenta has formed over the cervical os
 More common early in pregnancy
and usually resolves
 As the cervix dilates it tears the placenta apart
 Blood loss for both mom and baby
 Ranges in severity
 Known vs unexpected (no prenatal care)
 Prepare for GA
 Fluid resuscitation
 Blood available
C/S
 Abruption
 Placenta has fully prematurely separated from Uterus
 True emergency
 Time from decision to incision very short = GA
 Blood loss mom and baby
 Chorioamnioitis
 Infection of the uterus and placenta
 Occurs in long labor
 Premature rupture of membranes
 Causes fever and malaise in mom
 Can cause septicemia
 Can cause septicemia in fetus
 Placenta can become less affective
 C/S if mom or baby are symptomatic
 Resolves with antibiotics for both
C/S
 Ruptured Uterus
 Multiparity
 Multiples
 Increased risk with each C/S
 Classical Incision prior
 TOLAC/VBAC
 Low severe unrelenting abdominal pain that does not
correlate with contractions
 History of any of the above
 True emergency = GA
 Possible Hysterectomy
 All hands on deck
C/S
 Failure to Descend
 Cervix is dilated but Jr just wont “come on down”
 Could be related to position of fetus
 OP (Occiput Posterior) or “Sunny side up”
 Fetus facing anterior
 Fetal intolerance to Labor
 NRFHT but there is time for regional
 Arrest of Dilation
 Cervix will not dilate despite induction efforts
 Maternal exhaustion
 Hard long labor
 Pushing for several hours, or refusal to push anymore
 Maternal Desire for C/S
 Britany Spears syndrome
 Chic way to have a baby
 Patients think C/S just as safe as vaginal
 Policies to thwart early (39 wks)
 C/S in otherwise healthy babies
 under way
 Most of the time these can be done under reqional
 Spinal or existing working epidural
 Take care to interrogate your epidural
 It may have been turned down to aid pushing efforts
 Mom in a very fragile state may cloud the issue
C/S – at a Glance
 Regional vs GA
 Time, ability/difficulty, failed regional
 Intubation Ready
 ETT airway adjuncts at the ready
 Intubation drugs easily accessed
 Emergency drugs at the ready
 Good IV access
 18g or better x1, x2 if there are ANY chances you will need one
 Stat Labs
 H/H, Plts, T&S, T&C low threshold to order blood products
 Uncross matched Blood if needed
 Rhogam = Mom+/-, Baby +/- prevents (–) mom from (+ ) baby
 Is there a neonatologist available/on call
 NRP – certified staff
 Infant airways/blades/ supplies
 Will my spinal wear off?
 Approx 2hrs should be enough time but
 Complications
 Residents/inexperienced staff
 0400 is no time to let the Med Student learn how to close
 Gentle encouragement can be used
Ok so now we are doing a C/S so
we can stop worrying right?
 Maternal Hemorrhage
 Uterine Atony – Uterus will not contract and continues to
bleed
 Long labor
 Multiparity/Multigravid
 Magnesium/Pitocin
 Anesthetic Agents
 Retained placental tissues
 Inability to stop the bleeding
 Unknown source/Occult source
 Coagulopathies
 Emergent surgery can cloud judgment

 Bladder and Bowel perforation

 Grab a snickers and prep for GA
C/S issues
continued
 Uterine Inversion – Uterus turns
inside out as placenta is removed
 This causes a massive amount of
blood loss
 May result in a hysterectomy if
not resolved quickly
 Uterine relaxants
 AA’s
 Nitroglycerine 200 mcs at a time
 Great my patient is exsanguinating
and I’m giving NTG
 GA – 2 IV’s - Transfuse
Common C/S Rescue drugs
 Uterotonics
 Methergine (methylergonovine) - 200 mcs IM q 2-4hrs not
to exceed 5 doses
 Contraindicated for HTN
 Hemabate (carboprost) – 250 mcs IM q 15 to 90 mins not to
exceed 2000 mcs
 Contraindicated for asthmatics – smooth muscle contraction
 Nausea/Vomiting
 Pitocin (oxytocin) – 10u IV with concomitant gtt of 20-40
units per 500/1000cc NS
 10u IU
 Hypotension and increased MHR
 Controversial dosing some studies suggest less is more
 Misoprostal - PR
Other Help
 PRBC’s
 Cell Saver/Salvage
 FFP
 Plts
 Cryo
 Factor VII
 New drugs on the horizon used in Europe
 Uterine Artery Coiling
 Hysterectomy
C/S
 Hemmorhage
 Uterine atony
 Retained Placenta
 Anticoagulation
 Surgical inability to stop bleeding
 Bladder/Bowel perforations
 Uterine inversion
Post Partum
 Post Partum Hemmorrhage
 Retained placenta
 Premies
 May need to go to the OR for D&C
 Use Epidural if still working
 24-72 hrs assume all the risks of active parturient patient
 Anesthesia choices based on other risk factors
 Full stomach
 airway
 No kiddo to worry about
 How much blood has she actually lost
 Look at pads
 Uterine atony
 Same as discussed
 Uterine artery coiling
 Hysterctomy
 DIC
 Post fetal demise
 Amniotic Fluid Embolism
Post Partum
 Uterine Artery Rupture/Aneurysm
 Coiling vs open surgery
 Possible Hysterctomy
 Renal Artery Rupture/Aneurysm
 Low incidence 0.015-1%
 Occult blood loss with no evidence of PPH
 Often missed on the DD
 S/S or retroperitoneal bleed
 Coiling vs .Surgery
Post Partum
 Amniotic Fluid Embolism – during birth/immediatley post
 Amniotic Fluid/Debris enters maternal blood flow
 Mimics anaphylactic reaction
 Shock
 Pulmonary edema/PE/ARDS
 Cardiac events
 Sepsis
 DIC
 Up to 50% death rate
 Supportive measures
 TX DIC
 Echmo
Drug abuse
 Epidemic use of IVD
 Heroin
 Meth
 Cocaine
 Hep C, HIV, methadone, subutex
 Prescription Meds
 Narcotics
 THC
 Unpredictable pain control
 Fetal issues – underweight, no prenatal care
 Small placenta, abruptions, spont early birth

 Long term issues with abuse

 IN A NUTSHELL
Regional first

Labs

Blood products

Prep for GA
airway

Follow your gut

Questions?????