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

Abstract

BackgroundMaternal 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 presentationWe 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.ConclusionA 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.

A case series of vital signs-controlled, patient-assisted intravenous analgesia (VPIA) using remifentanil for labour and delivery

“…However, there are case reports of respiratory arrest associated with remifentanil use in labour and apnoea has been reported in a parturient on remifentanil infusion with associated fetal bradycardia that required emergency caesarean section . There have been two separate cases of cardiac arrest presumably arising from remifentanil‐induced respiratory arrest . Both patients made a full recovery following resuscitation, albeit with a perimortem caesarean section.…”

“…In general, these episodes tend to be short‐lived and respond rapidly to stimulation and/or oxygen supplementation. Complete respiratory arrest, although rare, has been reported .…”

Patient-controlled intravenous analgesia remifentanil for labor analgesia

“…However, significant concern has been raised over the last couple of years that remifentanil PCIA during labor can cause potentially lethal respiratory arrest. Several case reports have been published since 2012 in which the administration of remifentanil PCIA resulted in respiratory arrest and/or cardiac arrest [13][14][15]. Several factors contributed to the remifentanil-induced morbidity such as previous opioid administration (O'Kinney et al and Marr et al) or erroneous drug dosing (O'Kinney et al).…”

Who knows how many anaesthetists we need?

“…The third article is a case report of cardio-respiratory arrest associ-ated with remifentanil PCA [5]. This is now the fourth case report of respiratory and/or cardiac arrest related to remifentanil in obstetrics published in the last year [5][6][7][8]. Why the sudden flurry?…”

“…Why does this frequent ventilatory depression progress only rarely to respiratory or cardiac arrest? In the recently published cases, the precipitating factors were sometimes clear, such as a drug dilution error that resulted in an accidental ten-fold dose increase [6] or the recent administration of other strong opioids [5]. Other factors are speculative and include the possibility of sequestration of drug within the arm veins because of compression from a blood pressure cuff or arm flexion, with the subsequent central release of multiple doses [7].…”