This is the case of a 36 yr old G2A1 female, a known case of chronic hypertension superimposed
with PIH, morbid obesity, who presented @ 33 POG with PPROM with failed induction for
emergency LSCS.
On presentation, pt’s BMI was 48 kg/m2, HR 82/min, BP 160/90 mm of Hg, RR 22/min, Pedal
edema present, airway was adequate with MPCL II and a difficult venous access.
Spinal anesthesia was planned as the technique of choice but failed, so general anesthesia had
to be given. Patient was induced with RSII. Pt continued to have high BP intra-op, ranging from
150-180 systolic and 90-110 diastolic. Opioids, NTG and B-blockers were given intra-op to bring
BP under control. Inj Pitocin 5U bolus I.V. and Inj Carboprost 250mcg I.M. were given intra-op at
the request of the gynaecologist. Total i.v. fluid intra-op was 1000ml of crystalloids. There was 1
episode of desaturation intra-op to 88% which was managed by increasing FiO2 to 1. At the end
of the surgery , pt was reversed and extubated. Pt developed shallow breathing, started
desaturating, had b/l basal crackles on ausculatation and hence was re-intubated on ot table.
There was pink frothy sputum coming out of the ETT and the airway pressures very high.
Pulmonary Edema was suspected and Inj Lasix 40mg stat was given. Pt improved marginally
and was shifted to ICU immediately was further management.
On receiving the pt in the ICU, blood gas showed ph 7.14, PaCO2 81.7, PaO2 514.1 ( after bag
ventilation with 100% oxygen). Pt was put on ventilator support. Very high pressure support
and high PEEP was required to deliver the adequate tidal volume. Repeated endo-tracheal
suction was required. Inj Lasix 40 mg stat, Inj Morphine 3mg was given. Pt was put on Infusion
MGSO4 according to Zuspe’s regimen and on mild sedation along with antibiotics. An invasive
blood pressure line was here taken because of the inaccuracies in non-invasive BP monitoring,
owing to the very thick arm circumference. Pt remained stable with BP under control and
minimal endo-tracheal secretions. Hence after overnight mechanical ventilation on P-SIMV
mode and weaning off on CPAP/PS mode and a satisfactory blood gas report, the pt was
extubated the next morning. Post-extubation, the pt remained tachypnoeic (RR – 32-40/min),
most probably because of diaphragmatic splinting, because of large abdominal mass and lower
abdominal surgery. After 5-6 hrs, post-extubation, pt had sudden respiratory distress wid RR –
50/min, desaturation, b/l basal crepts and loss of consciousness. Pt was immediately taken on
Bains Circuit and intubated. Copious pink frothy secretions were being expressed from the ETT.
ABG at this time were ph 7.06, PaO2 120, PaCO2 124. ECG was showing st segment depression
in ant-lat leads. Pt was hyper-ventilated and upon return of spontaneous respiration, put on PSIMV mode Rate 25/min, PS 30, PEEP 10, FiO2 1. Inj Lasix 40mg and Inj Morphine 3 mg was
given. Cardiologist’s opinion was sought, who on echocardiography gave a probable diagnosis
of LV Diastolic Dysfunction with good contractility. Cardiac markers were done which were
negative for Ac Coronary Event. Pt was mechanically ventilated for one day and a half and
gradually pressures reduced. Presently was weaned off to CPAP mode and was tolerating well
at supports of 12-14. Here, Tab Enalapril 2.5mg was added to the prescription to suppress the
rennin-angiotensin-aldosterone system.
On post-op day 3, pt was extubated after giving a T-Piece trial, which pt tolerated well. Pt was
put on non-invasive ventilation at settings PS 14, PEEP 6, FiO2 0.4. Pt remained stable.
NIV was given intermittently for 24 hrs before pt was completely taken off ventilator support.
Pt was closely observed for one more day before being discharged to the ward, which was an
uneventful stay.
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