Monday 27 August 2012

Propofol Infusion Syndrome

PROPOFOL INFUSION SYNDROME
Scott E. Benzuly, MD
PROPOFOL INFUSION SYNDROME
  • WHAT IS IT
  • WHO IS AT RISK
  • WHAT CIRCUMSTANCES ARE NECESSARY
  • WHEN IS THE DIAGNOSIS MADE
  • WHEN SHOULD WE BE CONCERNED
  • WHY HAS IT TAKEN SO LONG TO FIGURE THIS OUT
Indications for sedation
Children
Respiratory disorders 1(5%) 21(31%)
Seizures 5(24%) 9(13%)
Head trauma/ICP control 5(24%) 9(13%)
Unspecified 10(47%) 4(6%)
Post surgical sedation 7(10%)
Agitation 5(7%)
Delirium Tremens 1(2%)
PROPOFOL INFUSION SYNDROME
    1. SUDDEN ONSET OF MARKED BRADYCARDIA, -RESITANT TO TREATMENT, -PROGRESSING TO COMPLETE HEART BLOCK
    2. LIPEMIC PLASMA
    3. CLINICALLY ENLARGED LIVER
    4. METABOLIC ACIDOSIS WITH A BASE DEFICIT OF > 10 MMOL/L ON AT LEAST ONE OCCASION
    5. RHABDOMYOLYSIS OR MYOGLOBINURIA 1
PRIS         
  • Propofol marketed in the USA since 11/1989.
  • PRIS has been described in both children and adult patients sedated with propofol.
  • FIRST CASE REPORTS- 1992
FDA Investigation of Deaths associated with Propofol
  • Reviewed reports of death with propofol as the suspect drug: pediatric pt(≤ 16y) and adults(>16y) for non-procedural sedation.
  • Time period= Nov 1989-Apr 2005.
  • Strict definition:
      • Metabolic acidosis and/or rhabdomyolysis with progressive cardiac failure US deaths for Nonprocedural sedation reported to the FDA
Deaths reported to the FDA

PRIS


                                                           CHILDREN                                 ADULT
Male8(38%)45(66%)
Female13(62%)22(33%)
Age range<16y19-86y
Peak dose (mean)13.7 mg/kg/h7.2 mg/kg/h
Median dose9.5 mg/kg/h5.4 mg/kg/h
Range2.2-54mg/kg/h0.6-25 mg/kg/h

PROPOFOL INFUSION SYNDROME
  • Propofol= Ideal PICU/ICU sedative
    • Hemodynamic stability
    • Lack of accumulation
    • Lack of withdrawal
Cardiovascular - failure, arrhythmia,
bradycardia, CV collapse and arrest
18(86%)
Metabolic acidosis 15(71%)
Hypotension 13(62%)
Rhabdomyolysis 11(52%)
 
PRIS
  • Common factors
    • Higher doses
    • Higher concentrations
    • Longer duration
PRIS
  • US Product labeling(PDR)
    • “Diprivan is not indicated for use in pediatric intensive care unit sedation because the safety of this regimen has not been established.”
  • Syndrome
    • Recognized in a retrospective cohort study of discharge diagnoses and medical records of 227 head injured adult patients age 16-55y admitted to INCU in The Netherlands between 1996-1999.
Time Line
  • 1989- Propofol released in US 11/1989
  • 1990- Danish Side Effect Committee- issued a warning after 2 yo girl developed hypotension, hepatomegaly and multiorgan failure associated with propofol infusion
Time Line
  • 10 yr experience:
  • 79 pt admitted to PICU for croup and long term ventilation
  • NO DEATHS OR SERIOUS ILLNESSES
Time Line
  • The Committee on Safety and Medicines (UK) and Astra-Zeneca issued serious adverse warnings about the use in PICU for sedation.
  • 1992- FDA Advisory Committee (Anesthetic and Life Support Drugs) - no direct link between these deaths and propofol.
Time Line
  • Since this time there have been at least 10 more reported cases in children with acidosis and arrhythmias( 7/10 died, 2/3 survivors treated with hemodialysis.
Time line
  • 2001 FDA, Canadian Health Protection Board issued a notice- strict adherence to approved indications for propofol.
  • Included was a letter from Astra-Zeneca informing users of the FDA findings that there may be serious safety concerns regarding the use of propofol for sedation in critically ill children.
Unpublished FDA multicenter randomized controlled trial #0859IL-0068.
  • 327 pediatric ICU patients
  • Comparing 3 regimens:
    • 1% Propofol
    • 2% Propofol
    • “Standard sedative drugs”
Unpublished FDA multicenter randomized controlled trial
MORTALITY
1% Propofol 8%
2% Propofol 11%
Standard sedatives 4%
PRIS
  • Common factors
    • Higher doses
    • Higher concentrations
    • Longer duration
  • “Organ toxicity and Mortality in Propofol-Sedated Rabbits under Prolonged Mechanical Ventilation”
4 Ypsilantis P, Politou M, et al. Anesth and Anal 2007; 105: 155-166.
  • Group P-
    • 2% propofol infusion
  • Group S
    • - Sevoflurane
  • Group S+IL-
    • Sevoflurane + Intralipid
ANIMAL MODEL FOR PRIS
Mortality Lab Findings
2% Propofol 100% ¯Sp02,Pa02, ® ¯C.O. ¯U.O.,ABP, ­HR
Sevoflurane 0% ­HR,CK,TGL
Sevo + IL 0% ­CK.TGL
 
ANIMAL MODEL FOR PRIS
Frothy Pulm edema Sp02<90% Pa02<90 @ Fi02=1.0 Bronchitis (eosinophils)
2% Propofol + + + _
Sevoflurane _ _ _ Low grade,mainly around bronchi
Sevo + IL _ _ _
ANIMAL MODEL FOR PRIS
Liver Gallbladder
2% Propofol No lesion
Sevoflurane No lesion,few inflammatory cells No lesion
Sevo + IL Slightly milky tincture,
Low grade fatty changes-steatosis,
Low grade active hepatitis Inflammatory cells around portal tracts and hepatocytes
Few inflammatory cells-submucosa
 
ANIMAL MODEL FOR PRIS
Kidney Bladder
2% Propofol
Sevoflurane No lesions 3/6. Few scattered lymphocytes in parenchyma
Sevo + IL Few scattered lymphocytes in renal parynchema Few inflammatory cells-submucosa
Case Report
  • 2yo boy PICU s/p shot in the head with an air gun pellet.
    • Intubated and ventilated for right sided cerebral edema and rim of subdural blood.
    • Sedated with propofol rate of 4-5.4 mg/kg/h. over 72 h.
  • Day 4
    • oliguria, increase in K+,BUN, Cr and then sudden, persistent bradycardia(HR= 28).
    • Propofol stopped, trans-venous pacer placed, restored HR but had persistent acidosis.
  • Diagnosis: PRIS- started dialysis. Complete recovery.
What should we do
  • High index of suspicion
    • > 48h propofol sedation
  • Turn off the propofol
  • Labs:
    • ABG
    • Triglycerides
    • Lactate level
What to do
  • Hemodynamic maintenance
    • Pressors
    • Transvenous pacing
  • Adequate oxygenation
  • Increasing Lipemia should not be considered benign
  • Add sugar to IV fluids
  • Hemodialysis
Who should not receive Propofol for Non-procedural sedation
  • Mitochondrial disease
  • Neuromuscular disease
Who should not receive Propofol for Non-procedural sedation
  • Mitochondrial disease
  • Neuromuscular disease
download lecture presentation  The Upper ExtremityPropofol Infusion Syndrome

Wednesday 22 August 2012

Compatibility Testing for Blood Transfusion


Untitled DocumenCompatibility Testing for Blood Transfusion  
ISBT = International Society of Blood Transfusion                                             















Recognizes the Presence of Multiple                  
Antigens on the Surfaces of   Red Blood Cells that define
Blood Group Systems 
 



 
Population Distribution of
Major Blood Groups

 
O       Rh       pos          38%
 
O       Rh       neg          7%
 
A       Rh      pos           34%
 
A        Rh     neg          6%
 
B        Rh     pos            9%
 
B        Rh     neg           2%
 
AB     Rh     pos            3%
 
AB    Rh      neg           1% 

 
Compatibility testing is done to avoid hemolytic transfusion reaction
 
If the Host or Recipient recognizes the donor RBC surface antigens as foreign,
the host will mount an immune response to the donor RBC’s
 
Major Blood Groups
  
ABO
ABO blood group antigens present on red blood cells and IgM antibodies
present in the serum.
 
 
Why do we have Anti-A or Anti-B Antibodies???
 
They are not present in the newborn
They develop in the first years of life
 
Exposure to plant, bacterial, viral antigens provokes this response
 
Why do we have Anti-A or Anti-B Antibodies???
 
Viruses transmitted from the respiratory tracts of humans to other humans drag along various antigens including ABO blood group antigens.
Prime the newborn’s immune system.
Reduces transmissibility of viruses within a population.
 
Rhesus
 
47 Antigens make up the
Rhesus Blood Group
The most significant is the
D antigen
 
Major Blood Groups
Rhesus
 
47 Antigens make up the
Rhesus Blood Group
The most significant is the
D antigen
 
There is no naturally occurring
Anti D
Production of Anti D in the
RH negative recipient
requires previous exposure
to the D antigen
(in utero or by transfusion)
 
If red cells are administered
to an ABO- or D-incompatible recipient,
the recipient will mount an
antibody response to the foreign
RBC surface antigens
IgM is polyvalent
and fixes complement
 
Intravascular Clumping of Donor RBC’s
   
Clumps and extruded RBC stroma
result in organ dysfunction
and possible death
 
Incidence 1:38,000 – 1:70,000
Mortality 1:30

Other Blood Groups
 
No naturally occurring antibodies
Immune response requires
previous exposure
Weaker titers of univalent antibodies
 
Donor RBC’s coated with host antibodies
Image
 
Stiffer RBC membrane
Susceptible to attack by
splenic macrophages
 
But no
intravascular clumping
 
Bits of Donor RBC membrane
lost traversing splenic sinusoids
(extravascular hemolysis)
 
Spherocytes
Decreased RBC survival
 
Delayed anemia
Priming for worse reaction
 
Donor
Questionnaire:
Medical history
Lifestyle
Finger stick:
Checking Hct
 
Donor
Needs a Hct of 0.38
A drop of donor blood is placed into a
test tube containing a
CuSo4 solution
 
CuSo4 solution has a SG of 1.053
RBC with Hct > 0.38 sink to
the bottom of the test tube
 
Donor
 
Side sample (20cc) collected for testing:
Blood group and Infection
 
The bag is anticoagulated
 
The unit is labeled with a lot#
like any drug
e.g. LH59321
 
DIFFERENT LEVELS OF COMPATIBILITY TESTING

 
 
COMPATIBILITY TESTING
The purpose of pre-transfusion compatibility testing is to PREVENT hemolytic transfusion reaction
Clerical and technical components
 
Samples must be labeled at the bedside
Two methods of ID required:
Name, SSN, MR#, DOB
The phlebotomist must sign the tube
 
COMPATIBILITY TESTING
Lab checks:
 
Identity
Record of previous specimen
Record of previous ABO-Rh type
History of abnormalities
 
COMPATIBILITY TESTING
]
Processing the specimen:
 
ABO Group determined (forward and reverse)
D typing determined
Antibody screen will be performed
ABO/Rh identical or compatible blood will be made available
 
ABO TYPING
 
Front or forward type using monoclonal anti-A and anti-B (commercial)
The sample is diluted to Hct 0.08, the commercial antibodies added & the test tube is centrifuged
The RBC’s are then examined for clumping (gross observation, gel suspension)
 
Anti A Anti B Anti A Anti B
 
 
A IMAGE B
 
Anti A Anti B Anti A Anti B
 
 
AB O
 

Back or reverse type with A and B cells
 
Commercially available A and B cells are added to two tubes of plasma
 
AB B A O
IMAGE
 
How do we know whether or not the host (or recipient) has antibodies to minor blood group antigens?

 
Add commercial RBC’s with known important minor antigens on their surface to host (or recipient) plasma and centrifuge. Then incubate at body temperature for 15-30 minutes
Then add rabbit antiglobulin
If recipient antibodies have coated
commercial RBC surfaces
IMAGE
Possibly significant minor blood groups
 
MNS 002 37
P P1 003 1
RH RH 004 47
LUTHERAN LU 005 18
KELL KEL 006 21
LEWIS LE 007 3
DUFFY FY 008 6
KIDD JK 009 3
DIEGO DI 010 2
CARTWRIGHTYP 011 2

 
 

Monday 20 August 2012

Anesthesia for the Obstetrical Patient

Anesthesia for the Obstetrical                                                  
Patient
         Fred Rotenberg, MD
         Dept  of Anesthesiology
  Rhode Island Hospital
       Grand Rounds February 27, 2008
Anesthesia for the Obstetrical Patient
         The Pregnant Patient for Nonobstetric Surgery
   LABOR
          DELIVERY
         OBSTETRICAL EMERGENCIES
          SPINAL HEADACHES AND BLOOD PATCHES
Alterations in Maternal Physiology
  Respiratory
   Increased O2 consumption
  Decreased FRC and pCO2 (increased MV)
   Cardiovascular
   Increased blood volume and CO
   Dilutional anemia
   Possible aorto-caval compression (when supine)
   GI
  Reduced gastroesophogeal tone
  Reduced anesthetic requirements (both GA & regional)
Anesthesia for the pregnant patient undergoing non-obstetric surgery
THE OBVIOUS
 AVOID MATERNAL HYPOXIA AND HYPOTENSION
THE NOT SO OBVIOUS
   Prevention / Treatment of preterm labor
   Probably NOT related to anesthetic management
   Due to SURGERY and/or underlying pathology
  Tocolytics (indocin or MAGNESIUM, hi dose volatile anesthetics)
   Teratogenic effects of anesthetics
  Benzodiazepenes? Nitrous oxide?
  NO GOOD EVIDENCE re: risk in humans
THE NOT SO OBVIOUS - continued
   Dose dependent effect of general anesthetics on fetal or newborn animals -
   Apoptotic neurodegeneration
   Persistent memory/learning impairments
  Therefore: USE AS LITTLE GENERAL ANESTHETIC (iv and volatile) as possible
Things we can (& should) do:
   If possible delay surgery til 2nd trimester
   Less risk of teratogenicity, miscarriage, than
1st trimester
  preterm labor more likely in 3rd trimester
  Left uterine displacement after 24th week
   Consider aspiration prophylaxis; midazolam (reduce maternal stress ->improve fetal blood flow)
   Consider Fetal monitoring (but no good data)
   Consult with obstetrician
ANESTHETIC CHOICES
   GA-preoxygenate, rapid sequence induction, slow reversal of relaxants, +/- N2O
   Loss of beat to beat FHR variability is normal;
   Fetal bradycardia is not!
   Regional anesthesia-minimal effects on fetus (assuming normal BP)
  Cut neuraxial dose of local anesthetic by 1/3rd compared to non-pregnant patient
   NO evidence showing better outcome
POST – OP
  Continue fetal monitoring
   Because of risk of thromboembolism:
   Early mobilization
   Consider anticoagulants
    Post op analgesia (regional is good at this)
LABOR ANALGESIA
Intravenous
Neuraxial:
Epidural
Spinal
Combined Spinal-Epidural
Goals of Labor Analgesia
  Adequate Analgesia
   Allow the mother to participate in birthing experience
   Minimal effect on the fetus
   Minimal effect on the progress of labor
Neuraxial Blockade
  A well conducted block provides the most effective and least depressant analgesic
   Spinal opiate (single shot) – fast onset, limited duration
   Continuous Epidural – slower onset, but duration is adjustable. Potential motor block.
  Combined Spinal Epidural – best of both
Arguments for epidural for Labor
   Relative risk of maternal mortality during C-section was 16x greater with GA compared to regional anesthetic
   Epidural for labor is now used in ~2.4m of the 4m total births in the US per year
Arguments against epidural for Labor
p  Incidence of epidural infection ~ 1/145k
p  Incidence of Epidural bleed ~ 1/150-170k
p  Incidence of persistent neurological injury ~ 1/237k (transient neurologic injury ~ 1/5,500)
p  Still about 20% of pts w/ labor epidural require conversion to GA for C-section
Disadvantages of epidural analgesia for labor
p  Slows labor by approximately one hour
p  Questionable effect on Cesarean Section delivery rate
p  Increases use of instruments during vaginal delivery
p  Increased incidence of maternal fever (and subsequent fever workup of mom and child)
Effect of Early Neuraxial Analgesia on C-Section Rate
p  Many older studies show no clear difference in section rate comparing neuraxial and parenteral opiate analgesia.
p  Wong et al. NEJM 2005
p  Prospective
p  demonstrates no increase in C-section rate comparing early vs later epidural opiate administration.
Epidural analgesia increases rate of instrument assisted deliveries
p  Rate of instrument assisted vaginal deliveries is at least doubled by epidural analgesia
p  Etiology of this effect?
n  Motor block from neuraxial local anesthetic
n  Epidural analgesia is associated with increased rate of occiput posterior presentation (does this painful presentation promote increased demand for epidural analgesia?)
n  The presence of a block might lower obstetrician’s threshold for using instruments
LABOR EPIDURAL
p  Continuous combined dilute local anesthetic plus opiate.
p  Better pain relief when combined; less motor block. Less instrumented deliveries. Minimal absorbtion by Mom or baby.
p  Eg: Bupivicaine 0.0625% plus 2ug/ml fentanyl (+/- epinephrine) @ 10-12 ml/hr.
Notes on epidural cath placement
p  Sterile technique
p  Loss of resistance to fluid (not air)
p  Prevent intrathecal placement (0.5-3% incidence)
p  Prevent intravenous placement (3-15% incidence) (use Arrow Flex-Tip; inject 10 ml dilute local through needle prior to cath placement).
p  Aspiration of blood or csf is quite reliable
Notes on epidural cath placement – 2
p  Epinephrine test dose is not sensitive for intravenous location.*
p  Local anesthetic (eg 45mg of Lido w/ epi) as test for intrathecal placement is somewhat better.
n  Wait 5 min after test to see motor changes.
n  Seek subjective change in pt’s ability to feel normal contraction of muscles controlling micturation.
n  Rapid profound analgesia suggests intrathecal dose.
Notes on epidural cath placement – 3
p  Safety is determined by the above careful placement AND
p  DOSE FRACTIONATION – give 3ml every 1-2 minutes.
p  “patience is wisdom and wisdom is patience”
Notes on epidural cath placement -4
p  For a “wet tap” consider:
p  Thread the epidural cath intrathecally and use it for continuous spinal. (Then leave it in place for 24 hrs to reduce the risk of spinal HA.)
p  Spinal catheter dosing: Bupiv 0.1% plus sufentanil 0.5ug/ml.  Start with 3 ml bolus; infuse a basal rate of 2 ml/hr; allow PCEA boluses of 1 ml q 30min prn.
Combined Spinal – Epidural Analgesia
p  Most beneficial in early or late labor (especially the multiparous patient)
p  #27 spinal needle through epidural needle – followed by epidural catheter insertion
p  Almost immediate pain relief with spinal opiate (fentanyl 10-25ug or sufentanil 2.5-10ug)
p  2-3 hour duration of analgesia with the spinal opiate
p  Patient may ambulate
Combined Spinal – Epidural Analgesia
p  In early labor (<4 cm dilation) CSE promotes more rapid cervical dilation than IV hydromorphone.
p  Also, high concentrations of local anesthetic slow labor.
Combined Spinal – Epidural Analgesia
p  For severe pain in the late stages of labor may need to add local anesthetic to spinal mixture.
p  Rx – Sufentanil 2.5-5ug plus bupivicaine 2.5 mg ->
p  Rapid profound analgesia without significant motor block.
p  Longer duration of analgesia than opiate alone.
Problems with Intrathecal Opiates
p  Pruritus – usually mild and short lived
p  Nausea and vomiting – best treatment?
p  Hypotension – Rx ephedrine.
p  Urinary retention
p  Uterine hyperstimulation and fetal bradycardia? (studies show no increased risk)
p  Maternal respiratory depression – monitor for at least 20 minutes post injection
Technical Problems with CSE
p  Post dural puncture headache
p  (Incidence is 1% or less)
p  Subarachnoid migration of epidural catheter?
p  Risk is remote – especially with separate port in epidural needle for spinal needle.
p  Still – use small incremental epidural doses
Patient Controlled Epidural Analgesia
p  May minimize drug doses, less motor block, but may provide inferior analgesia – should we add a basal infusion rate (6-9ml/hr)?
p  Must set limits to bolus doses. (4-6ml q 5-10min; max 4-6doses/hr)
p  Although less demands on anesthesia personnel, must still make periodic assessments.
Continuous Spinal Analgesia?
p  Microcatheters – are they associated with cauda equina syndrome?
p  28g microcatheters seem safe  (Arkoosh et al 2003) but are still not FDA approved.
p  Clearly increased risk of headache with larger catheters,  but advantage of controlled incremental dosing (cf epidural) may justify its use.
Anesthesia for delivery – Vaginal
p  Epidural “Perineal dose” for imminent delivery (10-12 ml of 0.062%bupiv + 50-100ug of fentanyl) to allow the pt to push
p  For forceps delivery or episiotomy repair: epidural 8-12 ml of 2% lido.
Anesthesia for delivery (Cesarian)
p  GETA
p  Spinal
p  Epidural
p  CSE
Regional anesthesia for C-section
p  Supplementation of Indwelling Epidural:
p  10-15ml of 1% lido or 0.125% bupiv, ropiviacaine or levobupivicaine.
p  Spinal (fast onset, dense block)
Spinal
p  Fast onset; profound anesthesia; avoid airway risks associated with GA
p  Recipe:Bupivicaine 6-12mg + 0.1mg MS
                or 20ug fentanyl (setup in 5 min; 2-4 hr duration)
p  Acute Hypotension prevention–> 1000-1500ml crystalloid immediately before spinal; left uterine displacement.
p  Tx of hypotension: Ephedrine (10mg) +/- phenylephrine
Post Dural Puncture Headache
p  Caused by decreased ICP, cerebral vasodilation
p  Dx: Postural component and cervical muscle spasm
p  Not always self limited, not always benign
n  Abducens N. palsy (visual problems)
n  Auditory disturbances
n  Subdural hematoma / hygroma
blood patch
p  Autologous blood patch is warranted –
n  Risk is small
n  Effective
p  Avoid in coagulopathy or febrile patient
p  Keep pt recumbent for 2 hrs after patch
p  Pts should avoid heavy lifting or Valsalva
p  Rx: stool softener and/or cough suppressant
p  Prophylactic blood patch is not warranted (blood patch is less effective if done in 1st 24 hours)
ASA Guidelines
p  Fetal Heart Rate monitoring before and after labor epidural
p  For elective cases, clear liquids acceptable up to 2 hrs preop; no solids for 6-8 hrs.
p  Timely administration of non-particulate antacids, H2 blockers and/or metoclopramide.
p  Pencil point spinal needles should be used rather than cutting needles to reduce PDP headache
ASA Guidelines – 2
p  For urgent delivery GA is faster than SAB which is faster than epidural
p  GA is associated with lower APGAR scores
p  Phenylephrine for maternal hypotension may cause less fetal acidosis than ephedrine infusions.
p  Cell saver should be considered for massive hemorrhage
ASA Guidelines – 3
p  Labor/delivery units should be equipped with difficult airway, fluid resuscitation and ACLS equipment
p  For maternal cardiopulmonary arrest (>4 min) consider emergent operative delivery of the fetus in addition to maternal resuscitation
p  Uterine displacement improves maternal venous return and should be routinely utilized
Anesthetic Management for Obstetrical Emergencies
“Nonreassuring” Fetal Heart Rate (ie “Fetal Distress”)
p  FHR deceleration related to uteroplacental insufficiency.
p  Prolonged / repeated deceleration of FHR may lead to fetal acidosis.
p  Lack of fetal heart rate variability may be due to fetal hypoxemia.
“Nonreassuring” Fetal Heart Rate (ie “Fetal Distress”)
p  Profound variable or late decelerations – especially if associated with decreased FHR variability dictates consideration of immediate delivery.
p  Fetal pulse oximetry, used in conjunction with FHR monitoring decreases emergent C-section rate related to “nonreassuring” FHR.
Image
PLACENTAL ABRUPTION
p  Premature separation of normally implanted placenta
p  May occur pre- or intrapartum (incidence ~ 1:80 deliveries)
p  Associated with maternal hypertension, heavy EtOH use or cocaine use.
p  Leads to maternal blood loss, neonatal neurologic damage or asphyxia

PLACENTAL ABRUPTION
p  May lead to consumptive coagulopathy and progress to DIC.
p  For suspected abruption – type and crossmatch blood; send H/H, plt count, fibrinogen and FSP’s
p  For severe abruption consider immediate C-section under GA.
p  Consider oxytocin and other uterotonic drugs and aggressive transfusion.
PLACENTA PREVIA
p  Abnormal implantation of placenta close to or over the cervical os.
p  Incidence: 1:200-250 deliveries (more common in multipara, prior C-section or previous placenta previa).
p  Common cause of 3rd trimester bleeding
p  For ongoing bleeding may require C-section
image
UTERINE RUPTURE
p  Often related to previous uterine scar from previous C-section
p  Sx: Vaginal bleeding, severe uterine pain, shoulder pain, disappearance of FH tones, hypotension.
p  Requires urgent delivery and abdominal exploration.
VBAC
p  In a prospective study between 1999-2002 ~18k women attempted VBAC; ~16k had elective repeat C-section
p  Symptomatic uterine rupture occurred in 124 (0.7%) of VBAC women
p  Hypoxic-ischemic encephalopathy occurred in 12 infants in VBAC cases; none in elective section
p  Lower incidence of maternal complications in elective section
POST PARTUM HEMORRHAGE
p  Retained placenta
n  Occurs in about 1% of deliveries
n  Requires manual exploration of uterus
n  1 MAC of GA provides uterine relaxation
n  NTG (100 ug) also provides uterine relaxation
POST PARTUM HEMORRHAGE – 2
p  Uterine Atony
p  Seen following 2-5% of deliveries
p  Associated with over distention of uterus, retained placenta, excessive oxytocin use during labor, and operative interventions.
p  Rx: Fluids, uterine massage and uterotonics.
Image]
THE END
p  THANKS FOR YOUR ATTENTION!



Saturday 18 August 2012

Lower Limb

The Lower Limb
Pelvis, Thigh, Leg
and Foot
Surface Anatomy
  • Gluteal region / posterior pelvis
    • Iliac crest
    • Gluteus maximus
      • Cheeks
    • Natal/gluteal cleft
      • Vertical midline; “Crack”
    • Gluteal folds
      • Bottom of cheek; “prominence”
 
Surface Anatomy
  • Anterior thigh and leg
    • Palpate
      • Patella
      • Condyles of femur
    • Femoral Triangle
      • Boundaries:
        • Sartorius (lateral)
        • Adductor longus (medial)
        • Inguinal ligament (superior)
      • Contents:
        • Femoral artery, vein and nerve, lymph nodes
Surface Anatomy
  • Posterior leg
    • Popliteal fossa
      • Diamond-shape fossa behind knee
      • Boundaries
          • Biceps femoris (superior-lateral)
          • Semitendinosis and semimembranosis (superior-medial)
          • Gastrocnemius heads (inferior)
        • Contents
          • Popliteal artery and vein
      • Calcaneal (Achilles) tendon
     Surface Anatomy
    • Anterior leg bones
      • Tibia
        • Tibial tuberosity
        • Anterior crest
        • Medial surface
        • Medial malleolus
      • Fibula
        • Lateral malleolus
    Bones of the Lower Limb
    • Function:
      • Carry weight of entire erect body
      • Support
      • Locomotion
      • Points for muscular attachments
    • Components:
      • Thigh
        • Femur
      • Knee
        • Patella
      • Leg
        • Tibia (medial)
        • Fibula (lateral)
      • Foot
        • Tarsals (7)
        • Metatarsals (5)
        • Phalanges (14)
    Thigh
    • Femur
      • Largest, longest, strongest bone in the body!!
      • Receives a lot of stress
      • Courses medially
        • More in women!
      • Articulates with acetabulum proximally
      • Articulates with tibia and patella distally
    Knee
    • Patella
      • Triangular sesamoid bone
      • Protects knee joint
      • Improves leverage of thigh muscles acting across the knee
    Leg
    • Tibia
      • Receives the weight of body from femur and transmits to foot
      • Second to femur in size and weight
      • Articulates with fibula proximally and distally
        • Interosseous membrane
    • Fibula
      • Does NOT bear weight
      • Muscle attachment
      • Not part of knee joint
      • Stabilize ankle joint
    Foot
    • Function:
      • Supports the weight of the body
      • Act as a lever to propel the body forward
    • Parts:
      • Tarsals
        • Talus = ankle
          • Between tibia and fibula
          • Articulates with both
        • Calcaneus = heel
          • Attachment for Calcaneal tendon
          • Carries talus
      • Metatarsals
      • Phalanges
     
    • Function:
      • Supports the weight of the body
      • Act as a lever to propel the body forward
    • Parts:
      • Tarsals
        • Talus = ankle
          • Between tibia and fibula
          • Articulates with both
        • Calcaneus = heel
          • Attachment for Calcaneal tendon
          • Carries talus
      • Metatarsals
      • Phalanges
    • 3 arches
      • Medial
      • Lateral
      • Transverse
        • Has tendons that run inferior to foot bones
          • Help support arches of foot
    Joints of Lower Limb
    • Hip (femur + acetabulum)
      • Ball + socket
      • Multiaxial
      • Synovial
    • Knee (femur + tibia)
      • Hinge (modified)
      • Biaxial
      • Synovial
      • Contains menisci, bursa, many ligaments
    • Knee (femur + patella)
      • Plane
      • Gliding of patella
      • Synovial
    Joints of Lower Limb
    • Proximal Tibia + Fibula
      • Plane, Gliding
      • Synovial
    • Distal Tibia + Fibula
      • Slight “give” (synarthrosis)
      • Fibrous (syndesmosis)
    • Ankle (Tibia/Fibula + Talus)
      • Hinge, Uniaxial
      • Synovial
    • Intertarsal & Tarsal-metatarsal
      • Plane, synovial
    • Metatarsal-phalanges
      • Condyloid, synovial
    • Interphalangeal
      • Hinge, uniaxial
    Muscles of Hip and Thigh
    • Gluteals
      • Posterior pelvis
      • Extend thigh
      • Rotate thigh
      • Abducts thigh
    • Anterior Compartment Thigh
      • Flexes thigh at hip
      • Extends leg at knee
    • Medial/Adductor Compartment
      • Adducts thigh
      • Medially rotates thigh
    • Posterior Compartment Thigh
      • Extends thigh
      • Flexes leg
    Gluteals
    • Gluteus maximus
      • Origin - Ilium, sacrum and coccyx
      • Insertion - Gluteal tuberosity of femur, iliotibial tract
      • Action - Extends thigh, lateral rotation & abduction
      • Innervation - Inferior gluteal nerve
    • Gluteus medius & Gluteus minimus
      • Origin – posterior Ilium
      • Insertion - Greater trochanter of femur
      • Action - Abduction, medial rotation
      • Innervation - Superior gluteal nerve
    • Lesser Gluteals help stabilize hip to allow fluent bipedal walking
    • Tensor fasciae latae
      • Origin – iliac crest and ASIS
      • Insertion – iliotibial tract
      • Action - Flex thigh, abduct thigh, medial rotation of thigh
      • Innervation – Superior gluteal nerve
    Anterior Compartment Thigh
    • Quadriceps femoris
      • Rectus femoris
        • Origin – anterior inferior iliac spine, margin of acetabulum
        • Insertion – patella and tibial tuberosity via the patellar ligament
        • Action – extends knee, flexes thigh
      • Vastus lateralis
        • Origin-lateral proximal femur, linea aspera
      • Vastus medialis
        • Origin-medial proximal femur, linea aspera
      • Vastus intermedius
        • Origin – ant & lateral femur
        • Insertion for all– patella and tibial tuberosity via the patellar ligament
        • Action – extends knee
      Anterior Compartment Thigh
      • Quadriceps femoris
        • Rectus femoris
          • Origin – anterior inferior iliac spine, margin of acetabulum
          • Insertion – patella and tibial tuberosity via the patellar ligament
          • Action – extends knee, flexes thigh
        • Vastus lateralis
          • Origin-lateral proximal femur, linea aspera
        • Vastus medialis
          • Origin-medial proximal femur, linea aspera
        • Vastus intermedius
          • Origin – ant & lateral femur
          • Insertion for all– patella and tibial tuberosity via the patellar ligament
          • Action – extends knee
      • All above innervated by the femoral nerve!!!
       
      Anterior Compartment Thigh
      • Sartorius
          • Origin - anterior superior iliac spine
          • Insertion – medial tibia
          • Action - flex, abduct, lat rotate thigh; weak knee flexor
      • Iliopsoas
        • Origin - Ilia, sacrum, lumbar vertebrae
        • Insertion – lesser trochanter of femur
        • Action – flexor of thigh
        • Innervation – femoral nerve
      Adductors
      • Adductor longus
      • Adductor brevis
      • Adductor magnus
        • Origin – inferior pelvis (details on pg 564)
        • Insertion – linea aspera of femur
        • Action – adducts and medial rotates
        • Innervation – Obturator nerve
      • Pectineus
        • Origin – pectineal line of pubis
        • Insertion – lesser trochanter of femur
        • Action – adducts, medial rotates
        • Innervation – femoral, sometimes obturator
      • Gracilis
        • Origin – inferior pubic ramus
        • Insertion – medial tibia
        • Action – adducts thigh, flex, medial, rotates leg
        • Innervation – Obturator nerve
      Posterior Compartment - Hamstring
      • Biceps femoris (2 heads)
        • Origin – ischial tuberosity (long) linea aspera of femur (short)
        • Insertion - lateral tibia, head fibula
        • Action - thigh extension, knee flexion, lateral rotation
      • Semitendinosus
      • Semimembranosus
        • Origin - ischial tuberosity
        • Insertion –proximal, medial tibia
        • Action - thigh extension, knee flexion, medial rotation
      Sciatic nerve innervates all of the above muscles!!!

      Muscles of the Leg
      • Anterior Compartment
        • Dorsiflex ankle, invert foot, extend toes
        • Innervation: Deep fibular nerve
      • Lateral Compartment
        • Plantarflex, evert foot
        • Innervation: Superficial Fibular nerve
      • Posterior Compartment
        • Superficial and deep layers
        • Plantarflex foot, flex toes
        • Innervation: Tibial nerve
      Anterior Compartment
      • Tibialis anterior
        • Origin - tibia
        • Insertion - tarsals
        • Action - dorsiflexion, foot inversion
      • Extensor digitorum longus
        • Origin – tibia and fibula
        • Insertion - phalanges
        • Action – toe extension
      • Extensor hallucis longus
        • Origin – fibula, interosseous membrane
        • Insertion – big toe
        • Action - extend big toe, dorsiflex foot
      • All innervated by deep fibular nerve
      Lateral Compartment
      • Fibularis (peroneus) longus
        • Origin – lateral fibula
        • Insertion – 5 th metatarsal, tarsal
        • Action - plantarflex, evert foot
      • Fibularis (peroneus) brevis
        • Origin – distal fibula
        • Insertion - proximal fifth metatarsal
        • Action – same as above!!
      All innervated by the superficial fibular nerve

      Superficial Posterior Compartment
      • Triceps surae
        • Gastrocnemius (2 heads)
          • Origin - medial and lateral condyles of femur
          • Insertion - posterior calcaneus via calcaneal tendon
        • Soleus
          • Origin – tibia and fibula
          • Insertion – same as above
        • Action of both – plantarflex foot
      • Plantaris
        • Origin – posterior femur
        • Insertion – same as above!
        • Action – plantarflex foot, week knee flexion
      All innervated by the tibial nerve
      Deep Posterior Compartment
      • Popliteus
        • Origin - lateral condyle femur
      and lateral meniscus
        • Insertion – proximal tibia
        • Action – flex and medially rotate leg
      • Flexor digitorum longus
        • Origin - tibia
        • Insertion - distal phalanges of toe 2-5
        • Action – plantarflex and invert foot, flex toe
      • Flexor hallucis longus
        • Origin - fibula
        • Insertion - distal phalanx of hallux
        • Action - plantarflex and invert foot, flex toe
      • Tibialis posterior
        • Origin – tibia, fibula, and interosseous membrane
        • Insertion - tarsals and metatarsals
        • Action - plantarflex and invert foot
      All innervated by the tibial nerve
      Muscles of the Foot
      • Dorsum of Foot
        • Extensor digitorum brevis
        • O: calcaneus, I: prox phalanx of hallux
        • Action: extend MT-P joint
        • Innervation = Deep Peroneal (Fibular) n.
      • Plantar Surface of Foot (= sole): 4 layers
        • O: Tarsals and/or Metatarsals, I: Phalanges
        • Action: Flex, Ext, ABduct, ADduct
        • Innervation: Medial + Lateral Plantar n. (from Tibial n.)
      Plexuses of the Lower Limb
      • “Lumbosacral plexus”
      • Lumbar Plexus
        • Arises from L1-L4
        • Lies within the psoas major muscle
      • Sacral Plexus
        • Arises from spinal nerve L4-S4
        • Lies caudal to the lumbar plexus
      Lumbar Plexus
      • Femoral nerve
        • Cutaneous branches
          • Thigh, leg, foot (e.g. saphenous nerve)
        • Motor branches
          • Anterior thigh muscles (e.g. quadriceps, sartorius, iliopsoas)
      • Obturator nerve
        • Sensory
          • Skin medial thigh; hip, knee joints
        • Motor
          • Adductor muscles
      • Lateral femoral cutaneous
        • Sensory
          • Skin lateral thigh
      • Genitofemoral
        • Sensory
          • Skin scrotum, labia major, anterior thigh
        • Motor
          • Cremaster muscle
      Sacral Plexus
      • Sciatic
        • Motor:
          • Hamstring
        • Branches into:
          • Tibial nerve
            • Cutaneous
              • Posterior leg and sole of foot
            • Motor
              • Posterior leg, foot
          • Common fibular (peroneal) nerve
            • Cutaneous
              • Anterior and lateral leg, dorsum foot
            • Motor
              • Lateral compartment, tibialis anterior, toe extensors
      • Superior gluteal nerve
        • Motor
          • Gluteus medius and minimus, tensor fasciae latae
      Sacral Plexus
      • Inferior gluteal nerve
        • Motor
          • Gluteus maximus
      • Posterior femoral cutaneous nerve
        • Sensory
          • Inferior buttocks, posterior thigh, popliteal fossa
      • Pudendal nerve
        • Sensory
          • External genitalia, anus
        • Motor
          • Muscles of perineum
      Arteries
      • Common iliac (from aorta) branches into:
        • Internal iliac
          • Supplies pelvic organs
        • External iliac
          • Supplies lower
      Arteries
      • Internal iliac branches into:
        • Cranial and Caudal Gluteals
      (Superior and Inferior)
          • Gluteals
        • Internal Pudendal
          • Perineum, external genitalia
        • Obturator
          • Adductor muscles
        • Other branches supply rectum, bladder, uterus, vagina, male reproductive glands
      Arteries
      • External iliac becomes…….
        • Femoral
          • Once passes the inguinal ligament
          • Lower limb
          • Branches into Deep femoral
            • Adductors, hamstrings, quadriceps
            • Branches into Medial/lateral femoral circumflex
              • Head and neck of femur
      • Femoral becomes……
        • Popliteal (continuation of femoral)
          • Branches into:
            • Geniculars
              • Knee
          • Splits into:
            • Anterior Tibial
              • Anterior leg muscles, further branches to feet
            • Posterior Tibial
              • Flexor muscles, plantar arch, branches to toes
      Veins
      • Deep Veins: Mostly share names of arteries
        • Ultimately empty into Inferior Vena Cava
          • Plantar
          • Tibial
          • Fibular
          • Popliteal
          • Femoral
          • External/internal iliac
          • Common iliac
      • Superficial Veins
        • Dorsal venous arch (foot)
        • Great saphenous (empties into femoral)
        • Small saphenous (empties into popliteal)