Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety
BMC Research Notes
Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety
Michelle A O Kinney 0 1
Carl H Rose 2
Kyle D Traynor 2
Eric Deutsch 1
Hafsa U Memon 2
Staci Tanouye 2
Katherine W Arendt 1
James R Hebl 1
0 Mayo Clinic , 200 First Street SW, Rochester, MN 55905 , USA
1 Department of Anesthesiology, Mayo Clinic , Rochester, MN , USA
2 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, MN , USA
Background: Maternal cardiovascular and pulmonary events during labor and delivery may result in adverse maternal and fetal outcome. Potential etiologies include primary cardiac events, pulmonary embolism, eclampsia, maternal hemorrhage, and adverse medication events. Remifentanil patient-controlled analgesia is an alternative when conventional neuraxial analgesia for labor is contraindicated. Although remifentanil is a commonly used analgesic, its use for labor analgesia is not clearly defined. Case presentation: We present an unexpected and unique case of remifentanil toxicity resulting in the need for an emergent bedside cesarean delivery. A 30-year-old G3P2 woman receiving subcutaneous heparin anticoagulation due to a recent deep vein thrombosis developed cardiopulmonary arrest during labor induction due to remifentanil toxicity. Conclusion: A rapid discussion among the attending obstetric, anesthesia, and nursing teams resulted in consensus to perform an emergent bedside cesarean delivery resulting in an excellent fetal outcome. During maternal cardiopulmonary arrest, a prompt decision to perform a bedside cesarean delivery is essential to avoid significant maternal and fetal morbidity. Under these conditions, rapid collaboration among obstetric, anesthesia, and nursing personnel, and an extensive multi-layered safety process are integral components to optimize maternal and fetal outcomes.
Perimortem cesarean section; Remifentanil; Pregnancy; Medication overdose
Background
Emergent bedside cesarean delivery is an intrinsically
unpredictable procedure performed for fetal indications
following a catastrophic event or injury when maternal
survival is uncertain. Under these conditions, a decisive
and cohesive plan of action on the part of labor and
delivery personnel, including anesthesia, obstetrics, nursing
and neonatology, is linked to fetal and maternal
prognosis [
1
]. We present a patient with a history of recent
venous thromboembolism who experienced an unexpected
cardiopulmonary arrest following implementation of an
intravenous remifentanil patient-controlled analgesic
(PCA) infusion for pain relief in labor and subsequently
underwent an emergent bedside cesarean delivery.
Case presentation
A 30-year-old G3P2 woman was admitted at 38+6 weeks
of gestation for elective induction of labor due to
concerns regarding intrapartum anticoagulation. The
current pregnancy was complicated by an episode of
idiopathic lower extremity deep venous thrombosis
(DVT) at 10 weeks estimated gestation at which time an
inferior vena caval (IVC) filter was placed. Following
placement of the IVC filter, therapeutic anticoagulation
was initiated with subcutaneous unfractionated heparin
for the duration of the pregnancy. The remainder of her
antecedent medical history was otherwise unremarkable.
Although the last injection of subcutaneous heparin
was administered 12 h before hospital arrival, the
patient’s activated partial thromboplastin time (aPTT)
was significantly elevated at 70 s (normal range: 21-33 s)
at the time of admission. The patient was subsequently
counseled that neuraxial analgesia was contraindicated
in the setting of an elevated aPTT due to an increased
risk of neuraxial bleeding. The decision was made to
ripen the cervix with misoprostol and administer
intermittent intravenous (i.v.) fentanyl as needed for labor
analgesia. The fetal heart rate pattern remained
reassuring throughout this period of time. A repeat aPTT
obtained 6 h later remained elevated at 80 s. After
discussing potential options with the patient, it was decided
to proceed with i.v. remifentanil patient-controlled
analgesia (PCA) based on our institutional protocol (basal
infusion: 0.03-0.05 μg/kg/min; bolus dose 0.2-0.8 μg/kg
every 5 min). A basal infusion rate of 0.04 μg/kg/min
(2 μg/min) with a bolus dose of 0.8 μg/kg (40 μg) every
5 min was ordered based on her ideal body weight of
50 kg. The medication was prepared by the hospital
pharmacy and placed in a barcode syringe for
administration in a Hospira LifeCareW Infusion System which
was connected to an 18-gauge cannula sited in the
woman’s left hand.
The remifentanil PCA was initiated after appropriate
medication review by anesthesia and nursing personnel,
confirming the drug, concentration, dose, and route of
administration and initiation of pulse oximetry. The
mother was supine, with left uterine displacement.
Within seconds of administering the first PCA dose, the
patient stated that she could not open her eyes and
rapidly became ri (...truncated)