• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Embolia polmonare in obstetrics
 

Embolia polmonare in obstetrics

on

  • 74 views

Pulmonary embolism in obstetrics form the anesthesiologist's point of view :written before 2005,date unknown

Pulmonary embolism in obstetrics form the anesthesiologist's point of view :written before 2005,date unknown

Statistics

Views

Total Views
74
Views on SlideShare
74
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Embolia polmonare in obstetrics Embolia polmonare in obstetrics Presentation Transcript

    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Embolia polmonare in ostetricia; dal punto di vista dell’anestesista-rianimatore Claudio Melloni Direttore Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Report on Confidential enquiries into maternal deaths in England and Wales 1970-1996 0 5 10 15 20 25 30 19 70- 72 73- 75 76- 78 79- 81 82- 84 85- 87 88- 90 91- 93 94- 96 Frequenza per milione di gravid.stimate emb.polm ipertens anest emb.fluido amniotico aborto gravid.ectopica emorragia sepsi rottura utero altre cause dirette Entrata in vigore della nuova classificazione
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Morti materne associate con l’anestesia in milioni di gravidanze stimate per England & Wales 0 5 10 15 20 25 30 35 40 45 50 70- 72 73- 75 76- 78 79- 81 82- 84 85- 87 88- 90 91- 93 94- 96 morti associate direttamente freq.per milione % delle morti dirette decessi per PE/per milione decessi per PE (num.ass.)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Da Parker,J,Schiffer,MA,Nelson,F.“Maternal and perinatal mortality”in Clinical management of mother and newborn,GF Marx ed.,Springer,New York 1979,pag 241-274. 0 5 10 15 20 25 30 Num % Maternal mortality,New York 1973-76;122 morti. emb.polm precl-eclampsia anest
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Da Parker 0 5 10 15 20 % Maternal mortality,New York 1980 gravid.ectopica ipertens emb polm accid cerebrovasc anestesia
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Maternal Mortality in The USA (Koonin et al.Maternal mortality surveillance,United yatetes,1980-85.MMWR 1989;37:19) 0 2 4 6 8 10 12 14 16 18 % embolism Hypertension Hemorrhage infection anesthesia ectopc pregnancy CVA cardiomyopathy other(& indirect)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Incidence of venous thromboembolism during pregnancy 0 0,05 0,1 0,15 0,2 0,25 0,3 0,35 Letsky 1984 Aaro 1971 Henderson 1972 Weiner 1985 Moore 1967 PE 12-25% untreate d Isotopic perfusion lung scanning and pulm angiography with clinical suspicion of PE
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) PE(CEMDUK) PE come causa maggiore di morte mort per TEB:2.1/100.000 gravid. 48 decessi,30 nel prec triennio 46 PE e 2 trombosi cerebrali 15 morti prenatali,25 postpartum
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Intervallo fra parto e PE(dati UK 1994-96) 0 1 2 3 4 5 6 gg 0-7 8_14 15-28 29-42 ?? parto vag C/S Ma la maggior parte delle DVT accadono antepartum;il 51% ver la 15 settimana….(Rutherford et al.Am J O
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Fattori di rischio(CEMDUK) Gravidanza come stato ipercoagulabile riposo a letto prolungato disidratazione chirurgia pelvica obesità fumo età materna > 35(5/100.000….) multiparità trombofilia(resist alla prot C attiva,mutaz nel coding del fatt V);deficit AT III,della prot C ,della prot S…... emorragia sepsi
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Gravidanza come fattore di rischio Puerperio * 6 C/S *10-20
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Gravidanza come fattore di rischioGravidanza come fattore di rischio Triade di VirchowTriade di Virchow IpercoagulabilitàIpercoagulabilità Stasi venosaStasi venosa Danno della parete venosa Danno della parete venosa
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Fattori di rischio per PE(Salonen H et al.Pulmonary embolism and stroke in relation to pregnancy:how can high risk women be identified? Am.J.Obstet.Gunecol 2002;186:198-203.) Età materna parità fumo preeclampsia;III trim RR 7 vs 3 non preeclamptic;puerperiumRR 8 ;stroke 12 RR gravid multipla,stroke risk 12 diabete C/S;parto e puerperio 7 RR vs vag;stroke risk 4 RR
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Prediction indexes for patients with DVT:(Wells et al.Value of assesment of pretst probability of deep vein thrombosis in clinical management.Lancet 1997;350:1795-98) Presence of active cancer presence of paralysis presence of a cast no alternative diagnosis(??) recent immobilization recent surgery tenderness along deep veins swelling of entire leg difference in calf circumference > 3 cm pitting edema presence of superficial veins
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Dehring DJ, Arens JF: Pulmonary thromboembolism: Disease recognition and patient management. ANESTHESIOLOGY 73:146-64, 1990 Segni e sintomi >50%:dispnea,tachipnea,tachicardia,apprensione,rant oli,tosse, II tono polm accentuato,dolore toracico(pleuritico/anginoso) <40%emottisi,febbre di grado medio,cianosi,diaforesi, segni di aumentata PVC, DVT clinica, sincope,alterato stato mentale. <10%wheezing,DIC,dolore addominale
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Dehring DJ, Arens JF: Pulmonary thromboembolism: Disease recognition and patient management. ANESTHESIOLOGY 73:146-64, 1990 Tests di lab: non esiste un esame singolo o una associazione che sia predittiva EGA:ipossiemia,ip ocapnia(ma non si può escludere PE con EGA normale) ECG: anormalità ST e T disturbi del ritmo:Exs atriali,ventric,tachi c atriale.. modificaz ventric dxsovracc atriale dx,RBB,R(L)AD,S1Q 3T3
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Dehring DJ, Arens JF: Pulmonary thromboembolism: Disease recognition and patient management. ANESTHESIOLOGY 73:146-64, 1990 Modificazioni RX atelectasis elevaz emidiaframma versam pleurico oligemia focale “knuckle sign” infarto polmonare
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Indagini diagnostiche( Toglia MR, Weg JG. Venous thromboembolism during pregnancy. N Engl J Med 1996; 335:108-14.) DVT: Pletismografia ad impedenza ultrasonografia real time B-mode ultrasonografia doppler Duplex PE: scan V/Q angiografia polm.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Miron et al. Clinical assesment of suspected deep vein thrombosis:comparison between a score and empirical assessment.J.Intern.Med. 2000;247:249-254. ..overall accuracy higher for the empiric asessment ,especially in patients categorized as high risk.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) H.Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen activator.Anesthesiology 89:1027-8, 1998 abruptio placenta and preeclampsia GA for C/S intraop life-threatening pulmonary embolism recombinant tissue plasminogen activator (rt-PA).
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen Activator.Anesthesiology 89:1027-8, 1998 35-yr-old woman at 29 weeks' and 4 days' gestation admitted from an outside institution for the treatment of abruptio placenta and preeclampsia no external vaginal bleeding the patient had undergone previous C/S for preeclampsia and prematurity;no history of pulmonary disease or DVT Ultrasonography revealed an estimated fetal weight of 1,212 g, and the fetal HR was > 100 beats/min. Results of blood tests performed at admission showed » HB: 7.6 g/dl (11.8 < normal < 13.0) » erythrocyte count: 3.30 106 /ml (3.74 106 < normal < 4.29 ´ 106)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen Activator.Anesthesiology 89:1027-8, 1998 GA+ETT induced using a rapid-sequence technique with cricoid pressure. Bilateral breath sounds were normal:SpO2 99% , ETCO2 26–28 mmHg. Just after delivery of a neonate, methylergometrine maleate was administered iv . A few min later, ETCO2 decreased suddenly to 9 mmHg. Simultaneously, it became difficult to ventilate the lungs, and 3 min later, SpO2 decreased from 99% to 19%. (FIO2 = 1.0) SBP progressively decreased from 140 to 80 mmHg, and the HR increased to 142 beats/min. 8 mg ephedrine was administered iv ;SBP recovered to 120 mmHg. 15 min after the decrease in blood pressure, an intraarterial catheter was inserted, EGA: pH = 6.93; PO2 =
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen Activator.Anesthesiology 89:1027-8, 1998 Dopamine infusion was started at a rate of 10 micro g×kg-1×min-1 and increased to 17 microg×kg-1×min- 1. Nevertheless, SBP decreased to 62 mmHg, and the HR decreased to 38 beats/min. Epinephrine was started at a rate of 0.133 microg×kg-1×min-1, with an increase in BP to 100/60 mmHg. SpO2 and ETCO2 monitoring showed 0% and 16 mmHg, respectively…….per 40 min…. .
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Nishimura et al. Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen Activator.Anesthesiology 89:1027-8, 1998 Based on a provisional diagnosis of pulmonary embolus, 5,000 u heparin followed by 5,000 u/h was administered. SpO2 increased to 50–60%. However, the patient continued to be hypoxic for 1 h, and her condition gradually deteriorated….. . A bolus of 1,800,000 units followed by 12,000,000 units/h rt-PA was then administered. 10 minutes later…. SpO2 dramatically increased to 100%. EGA pH: 7.328, PO2: 451.1 mmHg; PCO2: 49.2 mmHg; BE: -0.5 (FIO2 = 1.0).
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen Activator.Anesthesiology 89:1027-8, 1998 Chest RX performed in the OR was unremarkable. The patient was transferred to the ICU. 3 hours later, she recovered consciousness without neurologic compromise. However, her abdomen gradually became distended. There was external evidence of severe ongoing coagulopathy with bleeding from the vagina and the abdominal incision. Multiple transfusions of blood components were transfused for the next 35 h. Exploratory laparotomy for hemostasis of bleeding was performed through a midline incision the next day.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Treatment of Pulmonary Embolism during Cesarean Section with Recombinant Tissue Plasminogen Activator.Anesthesiology 89:1027-8, 1998 Although postoperative transfusions were necessary, coagulation test results returned to normal levels and bleeding decreased gradually. 14 days after delivery of a neonate, the patient was transferred to the obstetric ward. Pulmonary ventilation/perfusion scan 2 weeks after the operation was compatible with a large embolism to the left upper lobe; the patient eventually made a complete recovery.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Warning!! Obstetric delivery and major surgery within 7–10 days were classified as major relative contraindications by the National Institutes of Health (NIH) Consensus Conference because thrombolytic therapy also lyses other tissue clots…..
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward DK,Birks R, Granger KA.Massive pulmonary embolism in late pregnancy .Clinical Report Can J Anaesth 1998 ; 45: 888-892 A case of massive pulmonary embolism is described in a woman who presented in early labour at thirty-eight weeks gestation. Immediate management involved the administration of oxygen and intravenous heparin, and transfer to the regional cardiothoracic centre. Pulmonary angiography confirmed the diagnosis of massive pulmonary embolism, but attempts at percutaneous catheter disruption of the clot were of only temporary benefit. The patient subsequently underwent Caesarean section under general anaesthesia, followed minutes later (because of an abrupt deterioration in her condition) by surgical pulmonary embolectomy. The outcome was successful for both mother
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 A 25 yr old Caucasian woman in the 38th week of her 2nd pregnancy presented to the ante-natal ward of a local district general hospital with a two hour history of an abrupt onset of severe dyspnoea, chest tightness, and dizziness. Examination demonstrated central cyanosis and tachycardia, although she was normotensive (blood pressure (BP) 110/70 mmHg). A clinical diagnosis of pulmonary embolism was made, and, following initiation of treatment with oxygen and intravenous heparin, she was transferred immediately to the cardiothoracic unit at this hospital.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 On arrival on the CCU (4 hr after initial presentation), the patient was found to be conscious, tachypnoeic and cyanosed, with an SpO2 of 89% breathing oxygen by face mask (nominal FIO2 of 0.9). She was tachycardic (pulse rate 140 bpm) but remained normotensive (BP 125/75 mmHg). EGA: pH of 7.44, PaCO2 of 3.5 kPa, PaO2 of 7.7 kPa and BD of 5.3 mmol×l-1. An ECG demonstrated sinus tachycardia with partial RBB and right ventricular strain. Cardiotocography indicated fetal well-being (with a baseline rate of 150 bpm and good variability). The presence of regular `tightenings' and vaginal examination confirmed that the patient was in early labour.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 The immediate management of the patient was discussed with obstetrics, cardiothoracic surgery, cardiology, anaesthetics and radiology. In view of the evidence of early labour, it was considered that to provide the best chance of survival for both mother and child, delivery by urgent C/S was indicated. The need for surgical pulmonary embolectomy was a distinct possibility, and pulmonary angiography was required to confirm the diagnosis; attempts at mechanical clot disruption during this investigation also held the possibility of improving the patient's haemodynamic status. As the patient was at term and in early labour, and an active surgical approach to management had been selected, pharmacological thrombolysis to supplement percutaneous
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 The patient subsequently underwent pulmonary angiography (2 hr after arrival at our hospital), which confirmed bilateral large proximal pulmonary emboli, with preserved perfusion only of the left upper lobe. Attempts at mechanical disruption of the proximal thrombus using a pigtail catheter were met with some improvement in her symptoms and arterial oxygen saturation, and radiologically improved perfusion to the right lung. An infra-renal caval filter was inserted.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 However, the initial improvement in the patient's condition was not maintained, and re-examination within the hour confirmed progression of labour; the FHR remained satisfactory. It was, therefore, decided to proceed to delivery of the baby by C/S under GA with full preparation being made to proceed to emergency surgical pulmonary embolectomy if indicated.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 She received premedication with sodium citrate and 50 mg ranitidine iv, and a radial arterial cannula for blood pressure monitoring was secured. She was transferred to theatre 3 hrs 10 min after admission. Following pre-oxygenation, GA was induced with 500 mg alfentanil and 20 mg etomidate, and 100 mg succinylcholine was given to facilitate tracheal intubation after cricoid pressure was applied and tracheal intubation was easily performed. Maintenance of anaesthesia was by means of
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 A pre-induction BP of 140/70 mmHg decreased to 95/70 mmHg post-induction, and increased to 140/95 mmHg during delivery. A live but asphyxiated 3.8 kg male infant was delivered within ten minutes of induction of anaesthesia (and just under four hours after the patient had been admitted to this hospital). Apgar scores: 1 at 1 min; 2 at 5 min; 6 at 10 min; 8 at 15 min). Following administration of 10 IU syntocinon and fentanyl post-delivery, the BP decreased to 80/60 mmHg. A sinus tachycardia of 140–160 bpm persisted throughout this period. However, approximately 10 min after delivery, and while the uterus was being closed, the patient's BP decreased suddenly to 50/30 mmHg.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 On suspicion of a further massive PE, median sternotomy was performed, and normothermic, non- cardioplegic cavoaortic cardiopulmonary bypass was instituted following full heparinisation. A 20 cm length of embolic thrombus was extracted from the main pulmonary artery bifurcation. An innominate vein central line was inserted by the surgeon following embolectomy, (as attempts at internal jugular line insertion following delivery had been interrupted by the need to institute CPB); the CVP after separation from CPB was 10 cmH2O.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 Pre-operatively, Hb was 98 g×l-1 and platelet count 87 x l-1. Following delivery, perop Hb was 82 g×l-1, and decreased to 55 g×l-1 during cardiopulmonary bypass The patient received 3 units of blood (packed cells or SAG-M) in theatre and, subsequently, a further 3 units overnight in the CICU. In view of the pre-operative thrombocytopenia, period of CPB, and six unit blood transfusion, she was also given 5 units each of platelets and FFP in CICU. However, there was no evidence of excessive obstetric haemorrhage either in theatre or post- operatively. The patient's arterial blood gas values are recorded in the table.() Following extubation, she continued an uneventful post-
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Woodward & Granger.Massive pulmonary embolism in late pregnancy . Can J Anaesth 1998 ; 45: 888-892 conclusion, recent case reports support the use of thrombolysis and percutaneous catheter fragmentation in cases of massive P.E. occurring in pregnant women not in labour; furthermore, this should be performed early, and arguably does not require cardiac catheterisation facilities. Use of thrombolytic agents during labour and delivery can be expected to be associated with peri-partum haemorrhage, and the risks and benefits of conservative management vs thrombolysis or surgical embolectomy must be made on an individual basis in these patients. However, some maintain that thrombolysis should be strongly contraindicated in the peri-partum period until evidence from controlled trials is available. It may be that increasing experience with `clot specific' thrombolytic agents (e.g. rt-PA)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Flobdorf Th, Breulmann M, Hopf H-B. Successful treatment of massive pulmonary embolism with recombinant tissue type plasminogen activator (rt-PA) in a pregnant woman with intact gravidity and preterm labour. Intensive Care Med 1990; 16:454-56. 27 y,31st week preterm labour & tachypnea immobilization * preterm labour;2 weeks of tachypnea BP 80/50,HR 130,cyanosis (PaO2 72,PaCO2 28).
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Flobdorf et al. Successful treatment of massive pulmonary embolism with recombinant tissue type plasminogen activator (rt-PA) in a pregnant woman with intact gravidity and preterm labour. Intensive Care Med 1990; 16:454-56. R.HEART CATH;Mpap 36,RVp 50/20 : pulm angiography ;lack of perfusion of R upper & middle & lower lfet lobe dobutamine 5 microgr/kg/min urokinase 200.000 + heparin;obst objection…... further deterioration;BP 75/45,CVP 17, Mpap 39 ;HR 132,RAD+ST depression,neg T;paO2 72,PaCO2 25,O2 10 lt/min mask
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Flobdorf et al. Successful treatment of massive pulmonary embolism with recombinant tissue type plasminogen activator (rt-PA) in a pregnant woman with intact gravidity and preterm labour. Intensive Care Med 1990; 16:454-56. 2 hr without improvement;new consultation.. RTPA 10 mg/hr*4 hr,followed by 2 mg/hr * 1.30 hr,discontinued for slight bleeding from a puncture side(+ marked improvement)---300 UI heparin/kg/24 hr) “ subsequent” angiography;complete reperfusion RUL/RML & partial reperfusion LLB: coag tests normal; after 24 hr_transferred to ob ward;IInd day spont delivery of a male preterm infant(2100 gr); 2 weeks later heparin subst by oral coumarin:discharged at 4
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Flobdorf et al. Successful treatment of massive pulmonary embolism with recombinant tissue type plasminogen activator (rt-PA) in a pregnant woman with intact gravidity and preterm labour. Intensive Care Med 1990; 16:454-56. Haemodynamics time course 0 20 40 60 80 100 120 140 0 1 2 3 4 5 6 7 8 9 10 11 12 hr mmHG Mpap CVP HR MAP Rtpa Dobutamine
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) M,Furuya H.In Situ Pulmonary Thrombolysis Using Recombinant Tissue Plasminogen Activator after Cesarean Delivery .Anesthesiology, 91:578-9, 1999 . We successfully gave lower doses of recombinant tissue plasminogen activator (rt-PA) via a pulmonary artery catheter for thrombolysis in a 20-yr-old woman 2 days after a cesarean section. She was referred to us after an urgent CS at 34 weeks' gestation because of a suspected pulmonary embolism with concomitant fetal distress. Pulmonary embolism was suspected because of the sudden occurrence of consciousness troubles (confusion and disorientation), dyspnea, cyanosis, hypotension,
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Aya et al In Situ Pulmonary Thrombolysis Using Recombinant Tissue Plasminogen Activator after Cesarean Delivery .Anesthesiology, 91:578-9, 1999 She was treated prophylactically with subcutaneous low molecular weight heparin for 1 week. Heparin (5,000 units bolus and 1,000 units/h) was administered, but collapse and hypoxia persisted throughout the cesarean section despite the administration of fluids (2,500 ml) and mechanical ventilation with 100% oxygen. When she was admitted to our intensive care unit, the patient's systolic blood pressure varied from 50—100 mmHg, and hypoxia persisted (blood gas analysis with 100%
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Aya et al In Situ Pulmonary Thrombolysis Using Recombinant Tissue Plasminogen Activator after Cesarean Delivery .Anesthesiology, 91:578-9, 1999 The pulmonary artery wedge pressure could never be measured. Echocardiography showed a strongly dilated and hypokinetic right ventricle, with bulging of the interventricular septum into the left ventricle. Epinephrine and heparin administration and ventilation with a positive end-expiratory pressure (14 cm water) improved the patient's hemodynamic status (blood pressure, 140/90 mmHg; urine output, >0.5 ml × kg-1 × h-1; lactic acid, <2 mM/l; partial pressure of arterial oxygen, 135 mmHg with 80% oxygen), allowing further investigation.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Aya et al In Situ Pulmonary Thrombolysis Using Recombinant Tissue Plasminogen Activator after Cesarean Delivery .Anesthesiology, 91:578-9, 1999 Pulmonary angiography confirmed the pulmonary embolism and venocavography showed a compression on the left iliac vein (Cockett syndrome). Because of hemodynamic instability during the following 2 days, 60 mg rt-PA was administered over 6 h in situ via the pulmonary artery catheter but stopped at a cumulative dose of 57 mg because of bleeding on vascular puncture sites. No bleeding occurred from the wound or the uterus. Nevertheless, we obtained satisfactory
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Aya et al. Pulmonary Thrombolysis Using Recombinant Tissue Plasminogen Activator after Cesarean Delivery .Anesthesiology, 91:578-9, 1999
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Fine More cases following…..
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Kramer WB, Belfort M, Saade G, Surani S, Moise KJ Jr. Successful urokinase treatment of massive pulmonary embolism in pregnancy. Obstet Gynecol 1995; 86:660-2 A 20-year-old woman at 21 weeks' gestation presented to the ER history of worsening dyspnea and dizziness, and an episode of loss of consciousness lasting 1-2 min. family history of thromboembolic disorder, and her mother died at age 37 of a suspected PE admission: lethargic and had clinical evidence of respiratore distress;vital signs were: BP 82/58 mmhg, HR 132 RR 27,SaO2 90% on room air.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Kramer WB, Belfort M, Saade G, Surani S, Moise KJ Jr. Successful urokinase treatment of massive pulmonary embolism in pregnancy. Obstet Gynecol 1995; 86:660-2 Cardiac exam. was remarkable for an accentuated pulmonary component of the second heart sound, a strade 2 (of 6) systohc ejection murmur , and a right ventricular heave. The FHR was 150 beats per minute; no evidence of thrombophlebitis or edema. Apart from her lethargy, the neurologic examination was nonfocal. Abdominal ultrasound confirmed a singleton intrauterine pregnancy at 21 weeks' gestation. ECG revealed sinus tachycardia with S1Q3; chest RX showed no vascular markings over the left lung field.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Kramer et al. Successful urokinase treatment of massive pulmonary embolism in pregnancy. Obstet Gynecol 1995; 86:660-2 A PE was diagnosed, and the patient was admitted to the obstetric intensive care unit and started on intravenous (IV) heparin. An emergency radionuclide ventilation perfusion lung scan indicated a high probability for pulmonary embolism. The echocardiogram revealed severe right ventricular and right atrial enlargement, right ventricular wall hypokinesia, and bulging of the interatrial septum into the left atrium. These fìndings were believed to be consistent with increased right ventricular end-diastolic pressure. Right heart catheterization was performed via the left antecubital v. VVhile we attempted to float the inflated balloon into the pulmonary artery, circulatory collapse occurred with a sudden loss of consciousness. Immediate defiation of the balloon resulted in rapid recovery, and the patient regained conscious ness…..
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Kramer et al. Successful urokinase treatment of massive pulmonary embolism in pregnancy. Obstet Gynecol 1995; 86:660-2 During this episode, the FHR decreased to 100 beats/min and required 30 min.to return to baseline. Initial data obtained using the pulmonary artery catheter are presented in Figure 1, The patient continued to show hemodynamic and respiratory deterioration despite heparin therapy, repeated fluid boluses of normal saline, and a dopamine infusion. Therefore, we instituted thrombolytic therapy with IV urokinase and discontinued the heparin infusion. An IV priming dose
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Kramer et al. Successful urokinase treatment of massive pulmonary embolism in pregnancy. Obstet Gynecol 1995; 86:660-2 Six hours after discontinuing the urokinase, the patient experienced an episode of dyspnea with sudden deterioration in her hemodynamic status. She responded to a fluid bolus and 100% oxygen through a non rebreather mask. This episode was thought to be secondary to‑ further pulmonary embolism, and the urokinase infusion was restarted after the priming dose was repeated. She experienced no further episodes of dyspnea or hemodynamic instability (Figure 1). Twelve hours later, urokinase was discontinued and IV heparin was restarted. Repeat echocardiogram showed a decrease in the size of the right atrium and ventricle with less bulging of the interatrial septum to the left. Impedance plethysmography and venography of the lower extremities were normal. The patient experienced no further episodes of hemodynamic instability, and her dyspnea improved every day. After 7 days of a continuous IV
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Discussion …..1 Considerable problems with obstetric haemorrhage have occurred, however, in a case reported in 1972 in which streptokinase was infused throughout labour and delivery, only being discontinued in the third stage due to persisting blood loss which was finally controlled with aminocaproic acid. In a more recent report, streptokinase was commenced for massive PE at 28 wk gestation, but was stopped after 10 hrs for the duration of a pre-term labour and delivery. It was recommenced eight hours later, but discontinued after
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Discussion 2…. The technique of percutaneous transvenous fragmentation of pulmonary emboli may be performed using catheters specifically designed for the purpose, or with conventional cardiac catheters. A case report of acute massive P.E. involving three non-obstetric cases demonstrated this to be a rapid and relatively non-invasive method of improving cardiac output in very sick patients. Two cases subsequently also received an infusion of streptokinase via a pulmonary artery catheter, although the dramatic haemodynamic improvement occurred prior to this, and was
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Discussion ….3 A case report in 1985 discussed a woman presenting at 35 wk gestation with a massive PE, in active labour. Despite cardiorespiratory compromise, labour was allowed to proceed and resulted, eight hours later, in the spontaneous vaginal delivery of a 2.3 kg live infant. Caesarean section was rejected as it was felt that the maternal risk was too great; any surgical intervention should be for `maternal indications' only (such as embolectomy for worsening status). Thrombolytic therapy was also rejected as carrying too high a risk. However, following delivery, elective
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Discussion….4 A case bearing some similarity to ours was reported in 1989, in which a woman presented with cardiorespiratory compromise due to acute PE, at 32 wk gestation. She was not in labour. Heparin was commenced four hours after admission, but there is no record of whether thrombolytic agents were considered. Five hours after admission, emergency Caesarean section was
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Marples IL, Heap M , Suvarna SK,Mills G H Acute right-to- left inter-atrial shunt; an important cause of profound hypoxia Br. J. Anaesth. 2000; 85:921-925 Three patients presented to our intensive care unit over a 3-yr period with profound hypoxia resulting from acute right-to-left inter-atrial shunt (RLIAS). Patient I was a 67-yr-old male with an atrial septal defect who became hypoxic and developed the rare sign of platypnoea following elective repair of an abdominal aortic aneurysm (breathlessness made worse when
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Skinner, Sean C., BAAnesth Analg 1996; 83:247–53 Patients with severe pulmonary embolism can suffer progressive hypercapnia refractory to supramaximal mechanical ventilation, and may require open-thoracic or transvenous emergency embolectomy in addition to anticoagulation and/or thrombolysis. The functional recovery of gas exchange would be signaled by an increase in pulmonary CO2 elimination and decrease in CO2 retention; such data could guide the course of operative embolectomy. Accordingly, we studied five chloralose-urethane anesthetized, mechanically ventilated dogs with open thoraces in which the right pulmonary arteries (RPAs) were reversibly occluded with cloth snares. After waiting for steady state, we abruptly released the snare to restore RPA perfusion and experimentally simulate resolution of pulmonary embolism. For 70 min we serially measure the CO2 volume exhaled per breath (VCO2,br), arterial, mixed venous, and end-tidal PCO2 (PaCO2, PCO2, PETCO2), cardiac output
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) embolism in pregnancy treated with streptokinase and percutaneous catheter fragmentation.Eur.Heart J. 1994;15:1281- 1283 We report a patient who suffered massive pulmonary embolism with circulatory collapse in the second trimester and who was treated with intravenous streptokinase followed by percutaneous mechanical dispersion of thrombus using a catheter and guide wire. She made an excellent recovery despite complicating anteparturn haemorrhage.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) P. K. MAZEIKA, C. M. OAKLEY .Massive pulmonary embolism in pregnancy treated with streptokinase and percutaneous catheter fragmentation.Eur.Heart J. 1994;15:1281- 1283 In life threatening circumstances‑ pharmacological thrombolysis is mandatory particularly for hospitals without a cardiac catheterization laboratory on site…..
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) MAZEIKA PK,OAKLEY , C. M. .Massive pulmonary embolism in pregnancy treated with streptokinase and percutaneous catheter fragmentation.Eur.Heart J. 1994;15:1281-1283 A 34 year old w.,25 weeks ,Ist pregnancy‑ ‑ admitted with worsening exertional dyspnoea over 2 weeks. no past history of venous thromboembolism,pregnancy uncomplicated. On examination she was mildly breath less,centrally cyanosed with a raised jugular venous pressure. HR 124 beats/ min,BP 110/70 mmHg. no clinical evidence of deep vein thrombosis. RX unremarkable ;ECG S,Q,T, pattern. P02 8.7 kPa, PC02 3,2 kPa.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) MAZEIKA PK,OAKLEY , C. M. .Massive pulmonary embolism in pregnancy treated with streptokinase and percutaneous catheter fragmentation.Eur.Heart J. 1994;15:1281-1283. Following transfer to the intensive care unit and after discontinuing streptokinase (total dose 1400 000 U) she began bleeding from the os cervix. Prothrombin time was 26 s, partial thromboplastin time 42 s and fibrinogen I g. I Heparin was stopped, FFP and cryoprecipitate were administered and she required 4 u blood under cvp monitoring. The FHR remained stable throughout and an ultrasound scan of the uterus showed intact membranes and no evidence of retroplacental haemorrhage. Iv heparin was
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) MAZEIKA PK,OAKLEY , C. M. .Massive pulmonary embolism in pregnancy treated with streptokinase and percutaneous catheter fragmentation.Eur.Heart J. 1994;15:1281- 1283.
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Data from reports on fetal and maternal outcome after thrombolytic treatment for PE in pregnancy Author ca se s wee ks stage Mat erna l Ko Fetal outco me Ther Hall 1972 1 32 labour PPH ok streptk Fagher 1990 1 28 labour PPH ok streptk Ludwig 1973 24 14-40 antepartum none Ok streptk Pfeifer 1970 12 No data antepartum none Ok streptk Mc Taggart 1977 1 34 antepartum none Death in utero streptk Mazeika 1994 1 25 antepartum none Ok (CS) Streptk + cath.frag
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Author cas es weeks stage Maternal Ko Foe tus Ther Hall 1972 1 32 labour PPH ok streptk Fagher 1990 1 28 labour PPH ok streptk Ludwig 1973 24 14-40 antepartum none Ok streptk Pfeifer 1970 12 No data antepartum none Ok streptk Mc Taggart 1977 1 34 antepartum none Death in utero streptk AYA 1999 1 34+2 Post C/S none ok RTPA Flossdorf 1990 1 31 Preterm labour none ok Urok--RTPA Kramer 1995 1 21 antepartum none Ok urok Woodward 1998 1 38 antepartum haemorrhage Ok but rian Cath fragm + pulm embolect Mazeika 1995 1 25 antepartum No Ok,C/ Sterpt+cath Data from reports on fetal and maternal outcome after thrombolytic treatment for PE in pregnancy
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Amniotic fluid embolism (AFE)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) We read with interest the article by Bastien et al. describing the occurrence of a rare case of amniotic fluid embolism (AFE). They elegantly addressed the clinical features and the treatment of AFE, but we would like to emphasize some recent information that could lead to better treatment of this critical condition. Although the pathophysiologic responses seen with AFE are not
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Anesth Analg 1998; 87:124
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Shechtman M,Ziser A,Markovits R, Rozenberg B. Amniotic Fluid Embolism: Early Findings of Transesophageal echocardiography . Anesth Analg 1999; 89:1456–8
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Evitare: ipossia,ipercapnia,stress PG,ERGOT,KETAMINA,N2O BRADICARDIA DEPRESSIONE MIOCARDICA RIDUZIONE DELL’AFTERLOAD RIDUZIONE DEL PRELOAD(RITORNO VENOSO)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Coagulazione in gravidanza: Piastr norm o dim fatt VII,VIII,IX(=),X,XII + fibrinog + XI dim 62% protc C = prot S dim 40-50% AT III = PT dim APTT dim TT dim
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) trombofilie fAm,acquis storia di DVT,PE ricerca continua con avanzamenti rapodi trombosi art e ven storia di aborti rciorrenti,IUGR,preeclampsia episodi trombotici on the pill”
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Trombofilie congenite 19210079
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Tromboflie acquisite 19210080
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Disordini delle piastrine 19210081
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Preeclampsia & HELLP
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Dosrdini dei fattori delal coagulazione
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Esami di laboratorio Formazione del coagulo(coinvolge le pareti dei vasi,piastrine e sist. coagulativo…..) storia clinica,es obb consulto ematologico conta piastrinica tempo di sanguinamento PT,PTT,INR,fibrinogeno
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Problemi anestesiologici Raccomandazioni di Vandermeulen 1994 piastr> 80.000 INR non < 1.5 APTT limiti sup della norma tempo di sang = o > 8 min no storia di sanguinam anormale o bruising
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Raccomandaz per anest reg(Vandermeulen) Inserz adattata al trattamento spi> epid inserim atraumatico 4 cm catet nello spazio monitorizzazione vigile post partum
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) LMWH Horlocker 1997: ritarda inserz 10-12 h dopo LMWH ritarda rimoss catetere 10-12 h dall’ultima dose in caso di inserz traumatica,ritarda la dose successiva controlla coag prima della rimoss del catetere dopo rimoss del catetere ritarda la
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) I.V. heparin(Horlocker 1997) Ritarda inserim o rimoss 1 ora dalla dose
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) farmaci Eparina i.v. streptokinasi:streptase 250.000 0 750.000 u.;250.000/30 min poi 100.000/h sec.TT;*24-72 h? urokinasi;urokinase,actosolv,persolv,pur ochin,alfachinasi,ukidan 100.000 u persolv,alfachinasi e urokinasi anche da 1.000.000 :dosaggi 4400 U/kg /10 min poi /ogni h *12 h
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Eparina s.c. Ritarda inserz o rimoss 4 ore dalla dose con tutti gi agenti;usa misture oppioidi/LA
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Antepartum deaths from PE
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Antepartum deaths from PE: II
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Deaths from PE following C/S: I
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Deaths from PE following C/S
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Deaths from PE following vaginal delivery: I
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Daeths from PE following vaginal delivery
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) trattamento Rapido prima della dg definitiva??? Piena anticoagulaz con iv eparina LMW heparin filtri ilio-femorali
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Prevenzione Tromboprofilassi iniziata nel periodo prenatale……… identificazione dei gruppi a rischio: » valvole cardiache prostetiche » trombofilie » pregresse DVT e PE familiari » gli anestesisti hanno un ruolo da giocare….....
    • Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Non private le pazienti dei benefici della tromboprofilassi (e dei blocchi centrali……..)