Ob/Gyn Intensive care Unit Team

A. Personal history:

B. Brief anesthetic history:

Index

C. Sequence of events:

D. Primary ICU examination

and Resuscitation:

E. Management:
A. Personal history:
Age 19 yrs
Sex Female
Medical history Free
Obstetric history PG ,38 wks
Surgical history -ve
Allergy and drug history -ve
This patient was admitted for emergency C.S in the OR

B. Brief anesthetic history:

Preoperative anesthetic assessment was uneventful with normal labs:
Hb 12 mg/dl
Wbcs 6.9
Plts 169
INR 1
Creat 0.9
C. Sequence of events:

Patient received spinal Progressive hypotension

anesthesia with 2.1 ml of despite adequate fluid
Heavy Bupivacaine 0.75% replacement and 6 mg
Ephedrine increments

Endotracheal intubation after Near the end of operation

failed improving oxygenation ,Respiratory distress and
and diuretics (210mg Lasix) suspected pulmonary
edema

Transported to ICU ,Intubated

on AMBU bag , oxygen and
completely sedated
 D. Primary ICU examination
Examination:
and Resuscitation:
Conc. level Intubated,sedated
Vital data:
Pulse 130-140
regular sinus Cardiac Tachycardia with
exam galloping
B.pr 80/40 Bilateral equal air
entry with coarse
Spo2 75 % on 100 % Chest exam crepitations all
Fio2 over chest with
large quantities of
RBG 115 mg/dl active frothy
secretions from
Temperature 37 C ETT
Diagnostic adjuncts:
1. ABG:
PH 7.43
pco2 34mmHg

po2 92mmHg on
100%
Hb 9.9g/dl

HCo3 21mmol/L
Na 136 mmol/L
K 3.18 mmol/L
2. CXR:

Showed : Butterfly appearance of Bronchovascular

markings (Pulmonary edema and congestion) and
bilateral mild pleural effusion
3. ECG and Bedside
echocardiography:
ECG: Sinus tachycardia with pulse
140-160

Echo: EF:25% dilated left ventricle with

impaired systolic function, dilated both
atria,
With global hypokinesia, moderate MR,
severe TR with RVSP 52mmHg .
Following Ob/Gyn ICU
protocols for diagnosis of
this dilemma, It was
concluded that the most
probable cause for this
patient’s condition was :

Peripartum
cardiomyopathy
E. Management:
Again following our ICU
updated protocols for
management of peripartum
cardiomyopathy ,It was found
that it includes 3 main lines of
treatment :

1. Preload reduction

2. Afterload reduction

3. Inotropes
1. Preload reduction 2. Afterload reduction

❖ Central line inserted (CVP ❖ Low dose ACEI.

11cmH2o) with continuous
diuretic therapy and fluid ❖ Alpha/Beta blocker
restriction till full relief of (Carvedalol).
pulmonary edema.

❖ Patient’s had resistant hypoxia so ❖ Bromocriptine 2.5 mg

heavy sedation with complete twice daily.
muscle relaxation along with lung ❖ Therapeutic
protective strategy and anticoagulation
recruitment maneuvers were ❖ Pentoxifylline 400 mg
done. twice daily
3. Inotropes
Patient at first was on Adrenaline 250ng/kg/min and
Levophed 200ng/kg/min to maintain Tissue perfusion
and elevate Bpr. From 70/40 to 110/70 with considered
option of Intraaortic ballon device temporary placement
if failed Inotropes.
After 12 hrs. of admission Frothy sputum was almost minimal with same
hemodynamics and Hypoxic index 200

Patient’s Spo2 improved up to complete weaning

of mechanical ventilation and IV opioids (
After 36 hrs. Fentanyl) and extubation were done with
satisfactory ABG, and Bpr. 110/70 on Adrenaline
150ng/kg/min and Levophed 50 ng/kg/min with
fully conc. Cooperative patient.

After 72 hrs. Echo study was repeated revealing similar

contractility and EF.

After 8 days Patient was completely weaned from IV Inotropes

Good News : Discharged After Around 10 Days From ICU

admission
Thank you