Ob/Gyn Intensive care Unit Team

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

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
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 and
oxygen and sedated
 Primary ICU examination
and Resuscitation: Examination:
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
active frothy
RBG 115 mg/dl secretions from
ETT
Temperature 37 C
Diagnosis 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
 Patient transferred to ICU sedated, intubated, ventilated,
BP:80/40mmHg, HR:130bpm, SpO2:75%.
 Labs on admission:
HB:12.6mg/dl, TLC:6.9, plt:169, INR: ,92,creatinine:,8, Na:133mmol/l,
K:4.2mmol/l
 By auscultation: bilateral coarse crepitations allover the lung.

CXR:

ABG:
- ph:7.33, pco2:34.1mmhg, po2:72mmhg, Hco3:17.2mmol/l, base(def):-
5.6mmol/l,
- central venous catheter inserted : cvp was 11 cmH20.
bedside echo :
-EF:25%, dilated left ventricle with impaired systolic function, dilated both atria,
With global hypokinesia, moderate MR, severe TR with RVSP 52mmHg .

Icu management :
- Inotropes started:
- Dobutamine 10mcg/kg/min (with no improvement of BP) . Adrenaline
200ng/kg/min + levophed 150ng/kg/min was added instead (BP 100/55).
- Lasix infusion is started .
- Metabolic acidosis improved, after 36hr patient extubated after reduction of
inotropes doses .
- After extubation: spo2:95% on mask oxygen 5l/min, HR:96bpm, BP:100/60mmhg.
- ABG findings after extubation:ph:7.37, pco2:38mmhg, po2:76mmhg,HCO3 :19mmol

Cardioconsultation:
-Fluid restriction.
-antifailure measures :lasix ,ACEIs, BBs .

Patient transferred to internal medicine icu without any cardiac supports spo2:92% on
room air,HR:88bpm ,BP:105/60 .