Continuous Intravenous Infusion
Urine output > 25 ml/h
Patellar reflexes are present
Presentation : Any pregnant patient in the late second or third trimester who has elevated liver enzyme levels, especially in the presence of hypoglycemia. Also if patient presents with altered mental status and altered liver function in the postpartum period.
Preop optimisation : early recognition of liver dysfunction and aggressive resuscitation and treatment of hypoglycemia, DIC, and other associated complications.
Check the drug chart of the patient. Avoid / reduce dose of medications with substantial hepatic metabolism to prevent worsening encephalopathy
Consider reversal agents if the patient has received narcotics (ie, morphine)
If cesarean section is required, coagulopathy and thrombocytopenia should be corrected before surgery when possible
Anesthetist should be prepared for massive blood loss (eg, 2 large-bore intravenous catheters, blood products in room, fluid warmer and level 1 transfuser available, arterial line, and central line available).
Choice of anesthesia:
General anaesthesia may worsen or confuse the clinical appearance of encephalopathy. Regional techniques, however, may not be appropriate in those patients with worsening coagulation, and waiting for correction of any coagulopathy could lead to further deterioration in clinical condition. Regional anaesthesia can also cause hypotension and decrease hepatic blood flow.
If epidural analgesia is used for vaginal delivery, the epidural should be left in place until correction of coagulopathy.
High index of suspicion for epidural hematoma should be maintained :
Hourly neurological examinations and early surgical consultation should be made if deficits are identified.
The timing of surgery, usually in the first 48 hours after birth, is important because an increased infection rate is associated with delayed surgery
Check electrolytes, RFT
Check for associated anomalies like Chiari II malformation, scoliosis, renal anomalies, congenital heart disease and short trachea (Take care to avoid endobronchial intubation)
Positioning of a baby with a huge lumbar mass, will require thick sheets under the shoulder and similar head rings, for intubation. If it is associated with a Hydrocephalus, it can further complicate the airway management.
Take care in prone position to avoid undue pressure over body parts..facial oedema can occur postoperatively
Warmer should be arranged to avoid hypothermia; control the O.R. temperature
Respiratory complications : hypoventilation, sleep apnoea, bronchospasm, laryngospasm, prolonged breath holding as a result of structural derangement of medullary respiratory control
Cardiovascular complications: bradycardia, hypotension and tachycardia. Brainstem compression and coning causes most of the cardiac complications including cardiac arrest when Chiari malformation is associated with MMC.
Delayed recovery has to be anticipated...so arrange for postop ventilation ( Respiratory centre dysfunction, due to brainstem compression, if there, will again, increase the chance of requirement for post op ventilation)
Check for swallowing, gag reflex before extubation. Extubation should be performed only when the child is awake and breathing well.
Lower mortality can be achieved (27-37%), when early duagnosis made, and aggressive treatment implemented
Typical : Patient healthy prior to the onset of symptoms
ONSET: During or within 30 mins of labor ,cs ,dilatation and evacuation
Most important features :
OTHERS: Foetal distress, Seizures, Pulmonary edema, Uterine atony, Bronchospasm, Transient hypertension, Cough, Headache
".. Anesthesia and the Trendelenburg position increased the CVP, PCWP and pulmonary arterial pressures and decreased cardiac output. Pneumoperitoneum increased these pressures further mostly in the beginning of the laparoscopy, and cardiac output decreased towards the end of the laparoscopy. The risk of systemic CO2-embolus was increased during laparoscopy."
Ref: Acta Anaesthesiol Scand. 1995 Oct;39(7):949-55.
See the supraclavicular n., dat divides into medial n lateral br.s, supplies skin over deltoid..and skin over anterior chest
Lesser occipital, greater auricular, transverse cervical and supraclavicular nerves contribute to Superficial Cervical Plexus
Emerge from behind the midpoint of sternocleidomastoid
Blocking the superficial plexus
Short bevelled needle inserted posterior to midpoint of sternocleidomastoid
Injection immediately deep to superficial cervial fascia
Infiltration along posterior border of sternocleidomastoid superiorly and inferiorly
You can do it with USG also. Just behind SCM at its mid point most of the time EJV crosses. It's an added block to BPB in surgeries like clavicle fixation, AC joint fixation,shoulder repair etc
15 ml of lignocaine 1.5% or ropivacaine 0.75%
External or internal jugular vein injection