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Ultrasound in Critical Obstetric Situations: the Role of the Anesthesiologist

Ultrasound in Critical Obstetric Situations: the Role of the Anesthesiologist. Yaacov Gozal, M.D. Associate Professor of Anesthesiology Hebrew University and Hadassah Medical School Chair, Dept. of Anesthesiology Shaare Zedek Medical Center Jerusalem. INTRODUCTION.

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Ultrasound in Critical Obstetric Situations: the Role of the Anesthesiologist

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  1. Ultrasound in Critical Obstetric Situations: the Role of the Anesthesiologist Yaacov Gozal, M.D. Associate Professor of Anesthesiology Hebrew University and Hadassah Medical School Chair, Dept. of Anesthesiology Shaare Zedek Medical Center Jerusalem

  2. INTRODUCTION • Anesthesiologists: key role in high risk pregnancies • Member of a multidisciplinary team • ICU: 2-4/1000 deliveries

  3. INTRODUCTION • Traditionally: 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

  4. INTRODUCTION • Emergencies: quick and accurate diagnostic tools • Ultrasound: • Safe and easily accessible • Ease of use • Connectivity and data storage • Reduced size and weight

  5. Ultrasound • Routine locations: • Emergency Room • Delivery room • Operating Room • PACU • ICU

  6. Echocardiography • Provides volumetric and flow data • Shows the functioning heart • OB patient is the ideal subject: • Ant and left displacement of heart • Elevated diaphragm • Class I recommendation according to American, British and European guidelines

  7. The FATE Examination Jensen MB et al, Eur J Anaesthesiol 2004; 21:700-707

  8. The FATE ExaminationNormal Subcostal 4-Chamber View

  9. The FATE ExaminationNormal Apical 4-Chamber View

  10. The FATE ExaminationParasternal Long Axis

  11. The FATE ExaminationParasternal LV Short Axis

  12. LUNG ULTRASOUND • Acute respiratory failure: one of the most distressing situations • Physical exam. and chest X-Ray: imperfect • Need for sophisticated tests and delay management • Lung U/S: standard tool in critical care

  13. LUNG ULTRASOUNDBLUE-Protocol

  14. LUNG ULTRASOUNDBLUE-Protocol

  15. LUNG ULTRASOUNDNormal Lung

  16. LUNG ULTRASOUNDNormal Lung

  17. Postpartum Hypotension • 29-yr old primaparous • No significant medical history • Uncomplicated CS, with minimal blood loss under spinal anesthesia at 35 weeks’ gestation • 6 hrs after delivery: • Hypotension • Tachycardia • Febrile • Hb: 12

  18. Postpartum Hypotension

  19. Postpartum Hypotension • Hypotension due to cardiac failure • Dagnostic: postpartum cardiomyopathy • No signs of IHD (ECG, chest pain,..) • Treatment: • Inotropic support • Diuresis • ACE inhibitors

  20. Anaphylactic Shock • 35-yr old primaparous • No significant medical history • Delivery suite: epidural analgesia and urinary catheter • No progress CS • Baby delivered: hemodynamic collapse intubation, fluids, vasopressors

  21. Anaphylactic Shock

  22. Anaphylactic Shock • Adrenaline boluses • Steroids • H1 and H2 blockers • Adrenaline continuous infusion • Removal of the urine catheter

  23. Amniotic Fluid Embolism • 40-yrs old, gravida 5, para 4 • No remarkable medical history • Cesarean section at 38 weeks’gestation • Spinal anesthesia: hemodynamic stability • After delivery, CARDIAC ARREST • Cardiac massage • Epinephrine • Intubation and ventilation • VF: cardioversion X 6

  24. Amniotic Fluid Embolism

  25. Amniotic Fluid Embolism

  26. Amniotic Fluid Embolism • DIC: TEG flat • Thrombocytopenia • Supportive treatment

  27. Pulmonary Embolus • 35-yr old, Gravida 5, Para 3 • Vaginal delivery at 40 weeks’gestation • Postpartum hemorrhage • Atonic uterus: pitocin, methergin • Severe bleeding: 10 units RBC and 10 units FFP • During surgery, SaO2: 70% • Hemodynamic instability

  28. Pulmonary Embolus

  29. Pulmonary Embolus

  30. Pulmonary Embolus

  31. LUNG ULTRASOUNDPneumothorax

  32. LUNG ULTRASOUNDPneumothorax

  33. LUNG ULTRASOUNDAcute Dyspnea • 40-yrs old, gravida 3, para 2 • Acute respiratory distress at 31 weeks’ gestation • Medical background: asthma, morbid obesity and diabetes • Examination: • Tachypneic • SaO2: 85% (RA) • Bilateral wheezing • Lower limb edema

  34. LUNG ULTRASOUNDAcute Dyspnea

  35. LUNG ULTRASOUNDAcute Dyspnea B-Lines

  36. TTEAcute Dyspnea

  37. LUNG ULTRASOUNDAcute Dyspnea • Diagnosis: acute pulmonary edema rather than exacerbation of asthma • Management: diuretics and oxygen therapy Rapid Improvement

  38. CONCLUSIONS • Ultrasound: unique tool • Diagnostic and monitoring capabilities Ultrasound = 3rd eye of the anesthesiologist

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