Article Notes
- Need to prevent aortocaval compression.
- Early securing of the airway.
- Rapid perimortem Caesarean delivery.
- Likelihood of a non-cardiac/pregnancy cause.
- Recognition
- Calling for help
- A B C (D)
- Good for mother = good for baby
- Airway difficulties are more likely.
- Aortocaval compression dramatically impedes resuscitation – employ left lateral tilt!
- Consider perimortem cesarean section
- The presence of baby and gravid uterus severely limits resuscitation of the mother.
- Emergency cesarean section at cardiac arrest is done for the mother’s benefit, not the baby.
- A decision to perform emergency CS must be made within 4 minutes of arrest, and the baby delivered within 5 minutes. (Although there is some evidence of benefit when performed up to 10 minutes after arrest.)
- The only equipment required is a scalpel and an appropriately skilled doctor.
A very practical review of the evidence, indications and rationale for the perimortem cesarean section. Richard Parry describes the specific steps required to perform a PMCS, along with discussion of the pros and cons of different approaches. The importance of multidisciplinary training is emphasised.
A review of all published perimortem cesarean section case reports by Vern Katz, following up his article in 1986 first recommending this procedure.
While this does not offer proof of benefit (huge survival selection bias), of the 38 cases reported, 34 neonates survived (includes multiple gestations), and of the 20 cases with reversible causes, 13 mothers were discharged from hospital.
Katz writes:
In 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery.
This is the first published recommendation for perimortem cesarean sections in maternal cardiac arrest – from Katz, Dotters and Droegemueller (1986).
It was this recommendation that lead to the ‘4 minute rule’ for deciding to commence a CS in a resuscitation scenario, with the aim of delivering the baby within 5 minutes.
McDonnell makes a concerning observation regarding the ageing maternity population and subsequent potential for increasing rates of maternal arrest:
With the change in the obstetric population characteristic to women being older, heavier, and having more complex medical problems during pregnancy, the number of women who become seriously unwell while pregnant is likely to increase.
McDonnell highlights the differences in managing the collapsed parturient, namely:
The two cases presented include arrest due to ruptured uterus and arrest possibly due to iatrogenic magnesium overdose. Both resulted in favorable, though not perfect, outcomes for mother and baby.
The need for delivery suite ‘perimortem cesarean section packs’ is also discussed, as well as the use of regular simulation training.
The flaw with many closed loop TIVA-BIS studies, such as this one, is that they unquestionably assume reliability of BIS and are not powered for important morbidity or mortality outcomes.
This study while professing to show 'superiority' of a closed-loop system, really just shows that when given a monitor target the algorithm can more accurately and rapidly adjust the TIVA to maintain this. This may well be a good outcome, but does not necessarily equate to 'good' or safe anesthesia.
It's important to note that BIS has been validated essentially as an awareness alarm, not (yet) as a guide to appropriate depth of anesthesia.
A enjoyable trip down memory lane with Prof. Kester Brown. A brief description of the history of barbiturates and their structure activity relationships, culminating in the seven decade dominance of thiopentone.
The second half of this paper briefly describes the drugs that have challenged thiopentone, those you will likely have used (propofol, etomidate) and those most likely not (propanidid, althesin, gamma-hydroxybutyrate).
An quick and enjoyable read. Click through for the full-text.
Cardiac arrest is rare in pregnancy (1 in 30,000) and resuscitation is founded on the same approach used for the non-pregnant patient, focusing on:
However, unique to maternal resuscitation:
The rationale for Perimortem Cesarean Section is: