394
International Journal of Obstetric Anesthesia
We performed cardiopulmonary resuscitation despite a detectable carotid pulse as it was obvious that cardiac output was very poor. Despite all resuscitative attempts, relief of the inferior vena cava obstruction was considered to be the only treatment to restore her cardiac output. Guidelines recommend that in the event of cardiovascular collapse in the parturient, perimortem caesarean section should be considered if resuscitation efforts show no response within four minutes.9 If presented with such a situation again, we would secure invasive arterial monitoring. We would also counsel patients of risks associated with all forms of anaesthesia including surgical position in the presence of a multiple pregnancy, obesity and polyhydramnios.
C.J. Murphy, C.L. McCaul, P.C. Thornton Department of Anaesthetics Rotunda Hospital, Dublin, Ireland E-mail address: [email protected]
References 1. Pan P, Moore CH, Ross VH. Severe maternal bradycardia and asystole after combined spinal epidural labor analgesia in a morbidly obese parturient. J Clin Anesth 2003;16:461. 2. Kundra P, Velraj J, Amirthalingam U, et al. Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients. Anaesthesia 2012;67:889–93. 3. Jones SJ, Kinsella SM, Donald FA. Comparison of measured and estimated angles of table tilt at caesarean section. Br J Anaesth 2003;90:86–7. 4. Kundra P, Khanna S, Habeebullah S, Ravishankar M. Manual displacement of the uterus during caesarean section. Anaesthesia 2007;62:460–5. 5. Einav S, Kaufmann N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert based? Resuscitation 2012;83:1191–200. 6. Harvey NL, Hodgson RL, Kinsella SM. Does body mass index influence the degree of pelvic tilt used by a Crawford wedge? Int J Obstet Anesth 2013;22:129–32. 7. Bannerjee A, Stocche RM, Angle P, Halpern SH. Preload or Coload for spinal for elective cesarean delivery: a meta-analysis. Can J Anesth 2010;57:24–31. 8. Forrest JB, Rehder K, Cahalan MK, Goldsmith CH. Multi-center study of general anesthesia III. Predictors of severe perioperative adverse outcomes. Anesthesiology 1992;76:3–15. 9. Royal College of Obstetricians and Gynaecologists. Maternal Collapse in Pregnancy and the Puerperium Green-top Guideline No. 56. January 2011. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg56.pdf [accessed May 2015].
0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.05.003
Ilioinguinal-iliohypogastric block used to rescue ineffective transversus abdominis plane block after cesarean delivery Routine transversus abdominis plane (TAP) and ilioinguinal-iliohypogastric (IIIH) blocks have been studied as potential means of providing post-cesarean analgesia,1–4 but to our knowledge these blocks have never been directly compared. We report an interesting case that enabled evaluation of rescue TAP and IIIH blocks on the same patient, and demonstrated that successful TAP blockade does not always result in relief of Pfannenstiel incisional pain. A 28-year-old G2P1 woman at 39 weeks of gestation presented for elective cesarean delivery for breech presentation. She was morbidly obese (101 kg; body mass index 41 kg/m2) and on methadone maintenance therapy due to opioid dependence. The patient underwent spinal anesthesia with bupivacaine 12 mg, morphine 200 lg and fentanyl 15 lg. She also received intravenous ketorolac 30 mg and oral acetaminophen 1 g on arrival in the post-anaesthesia care unit (PACU). In view of opioid dependence, the patient was offered but declined preemptive IIIH blocks to help manage analgesia. After spinal block regression, she complained of severe incisional pain that remained uncontrolled despite multiple doses of intravenous hydromorphone. She was again counseled on the potential benefit of IIIH blocks and now wished to proceed. An 8–13 MHz linear ultrasound probe was used for all blocks, which were performed by a single experienced provider. The right IIIH nerves were readily identifiable in close proximity to a branch of the deep circumflex iliac artery as the ultrasound probe was positioned between the anterior superior iliac spine (ASIS) and the umbilicus, and an in-plane block was completed with 0.5% ropivacaine 20 mL injected 2–3 cm from the ASIS. There was difficulty identifying the left IIIH nerves because the abdominal wall layers could not be easily distinguished, so a TAP block was performed instead. The ultrasound probe was positioned along the anterior axillary line halfway between the lower costal margin and the iliac crest, and effective spread of medication within the TAP was visualized during injection of 0.5% ropivacaine 20 mL. It is unclear exactly why the left IIIH nerve was difficult to identify, but it may have been due to a combination of patient obesity, poor image quality, aberrant anatomy or post-surgical changes affecting the left lower abdominal wall. Subsequent examination revealed complete rightsided pain relief, as the IIIH block had produced a T11–L1 blockade to pinprick stimuli. However, the TAP block produced only a T8–T11 block and significant left-sided incisional pain remained. It was considered that the same factors that led to difficult left-sided ultrasound imaging may have led to inade-
International Journal of Obstetric Anesthesia quate spread of medication within the TAP. After discussion with the patient, repeat ultrasound imaging was attempted. Identification of relevant structures remained difficult, but eventually the IIIH nerves were identified in a similar location to those on the right side and blocked with 0.5% ropivacaine 15 mL. The total dose of ropivacaine 275 mg was less than the recommended maximum dosage of 3 mg/kg.5 Within minutes, the patient noted bilateral pain relief and now had a T8–L1 left-sided sensory blockade. She was monitored in PACU for another hour and then transferred to a postpartum ward. Sensation in the area of surgical incision was regained 18 h later, and the patient reported the pain as manageable as she was able to ambulate and care for her baby without difficulty. Rescue abdominal wall blocks can be effective in managing severe post-cesarean pain refractory to standard treatments.6 Previous reports have documented inconsistent sensory loss in the T12–L1 dermatomes after mid-axillary,7 posterior and subcostal TAP blocks,8 and improved T12–L1 sensory loss after IIIH blockade,7 and our case supports this observation. Medication is typically injected in the same anatomic plane for TAP and IIIH blocks, and thus TAP injections may successfully reach the IIIH nerves that innervate the dermatomal distribution of the Pfannenstiel incision.2–4 However, our case and others provide important examples that highlight the inconsistency of TAP blocks in this setting.7,8 Transversus abdominis plane medications may not achieve adequate spread to IIIH nerves given that their anatomical course may vary considerably with respect to the level at which they enter and leave the TAP in different individuals.7 A drawback of ultrasound regional techniques is reliance on the quality of images obtained, but we still prefer ultrasound over landmark-based techniques given the potential advantages of improved safety and greater block success rates.9,10 Further study is warranted to directly compare TAP and IIIH blocks for the management of Pfannenstiel incision pain. J.C. Coffman, K. Fiorini, R.H. Small Department of Anesthesiology Ohio State University Wexner Medical Center Columbus, OH, USA E-mail address: [email protected]
References 1. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2012;59:766–78. 2. Bell EA, Jones BP, Olufolabi AJ, et al. Iliohypogastric-ilioinguinal peripheral nerve block for post-Cesarean delivery analgesia decreases morphine use but not opioid-related side effects. Can J Anaesth 2002;49:694–700.
395 3. Wolfson A, Lee AJ, Wong RP, Arheart KL, Penning DH. Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia. J Clin Anesth 2012;24:298–303. 4. Vallejo MC, Steen TL, Cobb BT, et al. Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia. Sci World J 2012;2012:107316. 5. Williams DJ, Walker JD. A nomogram for calculating the maximum dose of local anaesthetic. Anaesthesia 2014;69:847–53. 6. Mirza F, Carvalho B. Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series. Can J Anaesth 2013;60:299–303. 7. Mei W, Jin C, Feng L, et al. Bilateral ultrasound-guided transversus abdominis plane block combined with ilioinguinal-iliohypogastric nerve block for cesarean delivery anesthesia. Anesth Analg 2011;113:134–7. 8. Lee TH, Barrington MJ, Tran TM, Wong D, Hebbard PD. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesth Intensive Care 2010;38:452–60. 9. McDermott G, Korba E, Mata U, et al. Should we stop doing blind transversus abdominis plane blocks? Br J Anaesth 2012;108:499–502. 10. Demirci A, Efe EM, Tu¨rker G, et al. Iliohypogastric/ilioinguinal nerve block in inguinal hernia repair for postoperative pain management: comparison of the anatomical landmark and ultrasound guided techniques. Rev Bras Anestesiol 2014;64:350–6. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.05.003
Anaesthetic management of a parturient with factor VII deficiency and sepsis Congenital factor VII deficiency is a rare autosomal recessive disorder with variable expression which can manifest as a wide spectrum of clinical phenotypes.1 It has an estimated incidence of one in 500 000. The severity of haemorrhage does not always correlate with the factor VII level.2,3 There are few reported cases of factor VII deficiency in pregnancy, with every patient receiving a different treatment regimen.4–7 We report a case of a parturient with mild congenital factor VII deficiency in which coagulation was further complicated by pregnancy-induced thrombocytopenia and urinary sepsis. A 27-year-old G3P2 woman (booking weight 70 kg, height 1.65 cm, BMI 25.7 kg/m2) was diagnosed with factor VII deficiency following two previous episodes of significant postpartum haemorrhage (PPH). Each episode was treated with packed red cells and platelets. Her baseline factor VII level was 24–35 IU/dL (normal range 50–150 IU/dL). At 10 weeks of gestation she was reviewed by her obstetrician and commenced on daily vitamin K 10 mg. At 28 weeks, she presented to the accident and emergency department with painless haematuria. She was apyrexial without cardiovascular
International Journal of Obstetric Anesthesia
We performed cardiopulmonary resuscitation despite a detectable carotid pulse as it was obvious that cardiac output was very poor. Despite all resuscitative attempts, relief of the inferior vena cava obstruction was considered to be the only treatment to restore her cardiac output. Guidelines recommend that in the event of cardiovascular collapse in the parturient, perimortem caesarean section should be considered if resuscitation efforts show no response within four minutes.9 If presented with such a situation again, we would secure invasive arterial monitoring. We would also counsel patients of risks associated with all forms of anaesthesia including surgical position in the presence of a multiple pregnancy, obesity and polyhydramnios.
C.J. Murphy, C.L. McCaul, P.C. Thornton Department of Anaesthetics Rotunda Hospital, Dublin, Ireland E-mail address: [email protected]
References 1. Pan P, Moore CH, Ross VH. Severe maternal bradycardia and asystole after combined spinal epidural labor analgesia in a morbidly obese parturient. J Clin Anesth 2003;16:461. 2. Kundra P, Velraj J, Amirthalingam U, et al. Effect of positioning from supine and left lateral positions to left lateral tilt on maternal blood flow velocities and waveforms in full-term parturients. Anaesthesia 2012;67:889–93. 3. Jones SJ, Kinsella SM, Donald FA. Comparison of measured and estimated angles of table tilt at caesarean section. Br J Anaesth 2003;90:86–7. 4. Kundra P, Khanna S, Habeebullah S, Ravishankar M. Manual displacement of the uterus during caesarean section. Anaesthesia 2007;62:460–5. 5. Einav S, Kaufmann N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert based? Resuscitation 2012;83:1191–200. 6. Harvey NL, Hodgson RL, Kinsella SM. Does body mass index influence the degree of pelvic tilt used by a Crawford wedge? Int J Obstet Anesth 2013;22:129–32. 7. Bannerjee A, Stocche RM, Angle P, Halpern SH. Preload or Coload for spinal for elective cesarean delivery: a meta-analysis. Can J Anesth 2010;57:24–31. 8. Forrest JB, Rehder K, Cahalan MK, Goldsmith CH. Multi-center study of general anesthesia III. Predictors of severe perioperative adverse outcomes. Anesthesiology 1992;76:3–15. 9. Royal College of Obstetricians and Gynaecologists. Maternal Collapse in Pregnancy and the Puerperium Green-top Guideline No. 56. January 2011. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg56.pdf [accessed May 2015].
0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.05.003
Ilioinguinal-iliohypogastric block used to rescue ineffective transversus abdominis plane block after cesarean delivery Routine transversus abdominis plane (TAP) and ilioinguinal-iliohypogastric (IIIH) blocks have been studied as potential means of providing post-cesarean analgesia,1–4 but to our knowledge these blocks have never been directly compared. We report an interesting case that enabled evaluation of rescue TAP and IIIH blocks on the same patient, and demonstrated that successful TAP blockade does not always result in relief of Pfannenstiel incisional pain. A 28-year-old G2P1 woman at 39 weeks of gestation presented for elective cesarean delivery for breech presentation. She was morbidly obese (101 kg; body mass index 41 kg/m2) and on methadone maintenance therapy due to opioid dependence. The patient underwent spinal anesthesia with bupivacaine 12 mg, morphine 200 lg and fentanyl 15 lg. She also received intravenous ketorolac 30 mg and oral acetaminophen 1 g on arrival in the post-anaesthesia care unit (PACU). In view of opioid dependence, the patient was offered but declined preemptive IIIH blocks to help manage analgesia. After spinal block regression, she complained of severe incisional pain that remained uncontrolled despite multiple doses of intravenous hydromorphone. She was again counseled on the potential benefit of IIIH blocks and now wished to proceed. An 8–13 MHz linear ultrasound probe was used for all blocks, which were performed by a single experienced provider. The right IIIH nerves were readily identifiable in close proximity to a branch of the deep circumflex iliac artery as the ultrasound probe was positioned between the anterior superior iliac spine (ASIS) and the umbilicus, and an in-plane block was completed with 0.5% ropivacaine 20 mL injected 2–3 cm from the ASIS. There was difficulty identifying the left IIIH nerves because the abdominal wall layers could not be easily distinguished, so a TAP block was performed instead. The ultrasound probe was positioned along the anterior axillary line halfway between the lower costal margin and the iliac crest, and effective spread of medication within the TAP was visualized during injection of 0.5% ropivacaine 20 mL. It is unclear exactly why the left IIIH nerve was difficult to identify, but it may have been due to a combination of patient obesity, poor image quality, aberrant anatomy or post-surgical changes affecting the left lower abdominal wall. Subsequent examination revealed complete rightsided pain relief, as the IIIH block had produced a T11–L1 blockade to pinprick stimuli. However, the TAP block produced only a T8–T11 block and significant left-sided incisional pain remained. It was considered that the same factors that led to difficult left-sided ultrasound imaging may have led to inade-
International Journal of Obstetric Anesthesia quate spread of medication within the TAP. After discussion with the patient, repeat ultrasound imaging was attempted. Identification of relevant structures remained difficult, but eventually the IIIH nerves were identified in a similar location to those on the right side and blocked with 0.5% ropivacaine 15 mL. The total dose of ropivacaine 275 mg was less than the recommended maximum dosage of 3 mg/kg.5 Within minutes, the patient noted bilateral pain relief and now had a T8–L1 left-sided sensory blockade. She was monitored in PACU for another hour and then transferred to a postpartum ward. Sensation in the area of surgical incision was regained 18 h later, and the patient reported the pain as manageable as she was able to ambulate and care for her baby without difficulty. Rescue abdominal wall blocks can be effective in managing severe post-cesarean pain refractory to standard treatments.6 Previous reports have documented inconsistent sensory loss in the T12–L1 dermatomes after mid-axillary,7 posterior and subcostal TAP blocks,8 and improved T12–L1 sensory loss after IIIH blockade,7 and our case supports this observation. Medication is typically injected in the same anatomic plane for TAP and IIIH blocks, and thus TAP injections may successfully reach the IIIH nerves that innervate the dermatomal distribution of the Pfannenstiel incision.2–4 However, our case and others provide important examples that highlight the inconsistency of TAP blocks in this setting.7,8 Transversus abdominis plane medications may not achieve adequate spread to IIIH nerves given that their anatomical course may vary considerably with respect to the level at which they enter and leave the TAP in different individuals.7 A drawback of ultrasound regional techniques is reliance on the quality of images obtained, but we still prefer ultrasound over landmark-based techniques given the potential advantages of improved safety and greater block success rates.9,10 Further study is warranted to directly compare TAP and IIIH blocks for the management of Pfannenstiel incision pain. J.C. Coffman, K. Fiorini, R.H. Small Department of Anesthesiology Ohio State University Wexner Medical Center Columbus, OH, USA E-mail address: [email protected]
References 1. Mishriky BM, George RB, Habib AS. Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2012;59:766–78. 2. Bell EA, Jones BP, Olufolabi AJ, et al. Iliohypogastric-ilioinguinal peripheral nerve block for post-Cesarean delivery analgesia decreases morphine use but not opioid-related side effects. Can J Anaesth 2002;49:694–700.
395 3. Wolfson A, Lee AJ, Wong RP, Arheart KL, Penning DH. Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia. J Clin Anesth 2012;24:298–303. 4. Vallejo MC, Steen TL, Cobb BT, et al. Efficacy of the bilateral ilioinguinal-iliohypogastric block with intrathecal morphine for postoperative cesarean delivery analgesia. Sci World J 2012;2012:107316. 5. Williams DJ, Walker JD. A nomogram for calculating the maximum dose of local anaesthetic. Anaesthesia 2014;69:847–53. 6. Mirza F, Carvalho B. Transversus abdominis plane blocks for rescue analgesia following Cesarean delivery: a case series. Can J Anaesth 2013;60:299–303. 7. Mei W, Jin C, Feng L, et al. Bilateral ultrasound-guided transversus abdominis plane block combined with ilioinguinal-iliohypogastric nerve block for cesarean delivery anesthesia. Anesth Analg 2011;113:134–7. 8. Lee TH, Barrington MJ, Tran TM, Wong D, Hebbard PD. Comparison of extent of sensory block following posterior and subcostal approaches to ultrasound-guided transversus abdominis plane block. Anaesth Intensive Care 2010;38:452–60. 9. McDermott G, Korba E, Mata U, et al. Should we stop doing blind transversus abdominis plane blocks? Br J Anaesth 2012;108:499–502. 10. Demirci A, Efe EM, Tu¨rker G, et al. Iliohypogastric/ilioinguinal nerve block in inguinal hernia repair for postoperative pain management: comparison of the anatomical landmark and ultrasound guided techniques. Rev Bras Anestesiol 2014;64:350–6. 0959-289X/$ - see front matter
c 2015 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2015.05.003
Anaesthetic management of a parturient with factor VII deficiency and sepsis Congenital factor VII deficiency is a rare autosomal recessive disorder with variable expression which can manifest as a wide spectrum of clinical phenotypes.1 It has an estimated incidence of one in 500 000. The severity of haemorrhage does not always correlate with the factor VII level.2,3 There are few reported cases of factor VII deficiency in pregnancy, with every patient receiving a different treatment regimen.4–7 We report a case of a parturient with mild congenital factor VII deficiency in which coagulation was further complicated by pregnancy-induced thrombocytopenia and urinary sepsis. A 27-year-old G3P2 woman (booking weight 70 kg, height 1.65 cm, BMI 25.7 kg/m2) was diagnosed with factor VII deficiency following two previous episodes of significant postpartum haemorrhage (PPH). Each episode was treated with packed red cells and platelets. Her baseline factor VII level was 24–35 IU/dL (normal range 50–150 IU/dL). At 10 weeks of gestation she was reviewed by her obstetrician and commenced on daily vitamin K 10 mg. At 28 weeks, she presented to the accident and emergency department with painless haematuria. She was apyrexial without cardiovascular
