Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety

BMC Research Notes, Dec 2012

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.

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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)


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Michelle A O Kinney, Carl H Rose, Kyle D Traynor, Eric Deutsch, Hafsa U Memon, Staci Tanouye, Katherine W Arendt, James R Hebl. Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety, BMC Research Notes, 2012, pp. 412, Volume 5, Issue 1, DOI: 10.1186/1756-0500-5-412