Ultrasound in Critical Obstetric Ultrasound in Critical Obstetric Situations: the Role of the Situations: the Role of the

AnesthesiologistAnesthesiologist

Yaacov Gozal, M.D.Associate Professor of AnesthesiologyHebrew University and Hadassah Medical SchoolChair, Dept. of AnesthesiologyShaare Zedek Medical CenterJerusalem

INTRODUCTIONINTRODUCTION

Anesthesiologists: key role in high risk pregnancies

Member of a multidisciplinary team

ICU: 2-4/1000 deliveries

INTRODUCTIONINTRODUCTIONTraditionally: background of previous

excellent health and large physiological reserve

Modern maternal characteristics:◦Increasing age◦Morbid obesity◦Congenital and acquired cardiac disease◦Assisted reproduction

Diagnostic dilemmas

INTRODUCTIONINTRODUCTION

Emergencies: quick and accurate diagnostic tools

Ultrasound: ◦Safe and easily accessible◦Ease of use◦Connectivity and data storage◦Reduced size and weight

UltrasoundUltrasoundRoutine locations:

◦Emergency Room◦Delivery room◦Operating Room◦PACU◦ICU

EchocardiographyEchocardiographyProvides volumetric and flow

dataShows the functioning heartOB patient is the ideal subject:

◦Ant and left displacement of heart◦Elevated diaphragm

Class I recommendation according to American, British and European guidelines

The FATE ExaminationThe FATE Examination

Jensen MB et al, Eur J Anaesthesiol 2004; 21:700-707

The FATE ExaminationThe FATE ExaminationNormal Subcostal 4-Chamber ViewNormal Subcostal 4-Chamber View

The FATE ExaminationThe FATE ExaminationNormal Apical 4-Chamber ViewNormal Apical 4-Chamber View

The FATE ExaminationThe FATE ExaminationParasternal Long AxParasternal Long Axisis

The FATE ExaminationThe FATE ExaminationParasternal LV Short AxisParasternal LV Short Axis

LUNG ULTRASOUNDLUNG ULTRASOUNDAcute respiratory failure: one of

the most distressing situationsPhysical exam. and chest X-Ray:

imperfectNeed for sophisticated tests and

delay managementLung U/S: standard tool in

critical care

LUNG ULTRASOUNDLUNG ULTRASOUNDBLUE-ProtocolBLUE-Protocol

LUNG ULTRASOUNDLUNG ULTRASOUNDBLUE-ProtocolBLUE-Protocol

LUNG ULTRASOUNDLUNG ULTRASOUNDNormal LungNormal Lung

LUNG ULTRASOUNDLUNG ULTRASOUNDNormal LungNormal Lung

Postpartum HypotensionPostpartum Hypotension29-yr old primaparousNo significant medical historyUncomplicated CS, with minimal

blood loss under spinal anesthesia at 35 weeks’ gestation

6 hrs after delivery: Hypotension Tachycardia Febrile Hb: 12

Postpartum HypotensionPostpartum Hypotension

Postpartum HypotensionPostpartum HypotensionHypotension due to cardiac failureDagnostic: postpartum

cardiomyopathyNo signs of IHD (ECG, chest pain,..)Treatment:

◦Inotropic support◦Diuresis◦ACE inhibitors

Anaphylactic ShockAnaphylactic Shock35-yr old primaparousNo significant medical historyDelivery suite: epidural analgesia and

urinary catheterNo progress CSBaby delivered: hemodynamic

collapse intubation, fluids,

vasopressors

Anaphylactic ShockAnaphylactic Shock

Anaphylactic ShockAnaphylactic Shock

Adrenaline bolusesSteroidsH1 and H2 blockersAdrenaline continuous infusion Removal of the urine catheter

Amniotic Fluid EmbolismAmniotic Fluid Embolism

Amniotic Fluid EmbolismAmniotic Fluid Embolism

Amniotic Fluid EmbolismAmniotic Fluid Embolism

Amniotic Fluid EmbolismAmniotic Fluid EmbolismDIC: TEG flatThrombocytopeniaSupportive treatment

Pulmonary EmbolusPulmonary Embolus35-yr old, Gravida 5, Para 3Vaginal delivery at 40

weeks’gestationPostpartum hemorrhageAtonic uterus: pitocin, metherginSevere bleeding: 10 units RBC

and 10 units FFPDuring surgery, SaO2: 70%Hemodynamic instability

Pulmonary EmbolusPulmonary Embolus

Pulmonary EmbolusPulmonary Embolus

Pulmonary EmbolusPulmonary Embolus

LUNG ULTRASOUNDLUNG ULTRASOUNDPneumothoraxPneumothorax

LUNG ULTRASOUNDLUNG ULTRASOUNDPneumothoraxPneumothorax

LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea

40-yrs old, gravida 3, para 2Acute respiratory distress at 31

weeks’ gestationMedical background: asthma,

morbid obesity and diabetesExamination:

◦Tachypneic◦SaO2: 85% (RA)◦Bilateral wheezing◦Lower limb edema

LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea

LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea

B-Lines

TTETTEAcute DyspneaAcute Dyspnea

LUNG ULTRASOUNDLUNG ULTRASOUNDAcute DyspneaAcute Dyspnea

Diagnosis: acute pulmonary edema rather than exacerbation of asthma

Management: diuretics and oxygen therapy

Rapid Improvement

CONCLUSIONSCONCLUSIONSUltrasound: unique toolDiagnostic and monitoring

capabilities

Ultrasound=

3rd eye of the anesthesiologist