On Call

I was on call yesterday. Another busy day.. Don't know why lately my on call are always busy :( Start my day at 8 am in the morning with a primigravida with cyanotic congenital heart disease, Tetralogy of Fallot (TOF) for Caesarean Section.

Tetralogy of Fallot (TOF) comprised of 4 seperate components, namely :
- Ventricular septal defect (VSD)
- Pulmonary Stenosis (PS)
- Right Ventricular Hypertrophy (RVH)
- Overriding Aorta (aorta lies directly over the ventricular septal defect).
Although it's very high risk surgery, luckily she doesn't has Eisenmenger Syndrome.

Clinically she is NYHA class 1 to 2 with central cyanosis. Her oxygen saturation under room air was 79 to 81%. With ventimask 60% oxygen, SpO2 was 89 to 91%. SBE prophylaxis given. I gave her epidural anaesthesia for the Caesarean Section with Intra Arterial Blood Pressure monitoring. It's very important to avoid any air bubbles inside the intravenous lines... Her haemodynamic was stable intra operatively. Surgery went on smoothly with minimal blood lost and she was sent to intensive care unit for post op close monitoring.

I have done few cases of Tetralogy of Fallot previously (with Eisenmenger Syndrome or pulmonary hypertension with Reversal of Shunt - Right to Left Shunt). Sad to say that most of them succumbed at the end.. This is indeed a very high risk condition with very high mortality rate. Pregnancy should be avoided in patients with Eisenmenger Syndrome because pregnancy carries very high mortality for these group of people, and death frequently occur during labour, or postpartum/post delivery.

Second case was a morbidly obese patient for elective Caesarean Section... She was too obese that we couldn't manage to get the subarachnoid space for Spinal Anaesthesia,even with the long spinal needle. Spinal Anaesthesia is the best choice for her cos she has very high risk for General Anaesthesia. Cos of the high possiblity of difficult intubation and high risk of aspiration of gastric content causing aspiration pneumonia. After several attempts by my consultant anaestesiologist and failed, we finally gave up trying spinal anaesthesia for her..

She was pre oxygenated adequately(obese people has reduced funtional residual capacity and tends to desaturate fast under anaesthesia) and induced with rapid sequence induction with cricoid pressure. No difficult intubation (Cormack & Lehane 1) but she desaturated pretty fast. Needed manual ambubagging for quite a while post intubation with 100% oxygen and PEEP to mantain her saturation. She also needed high PEEP intra operatively.

Subsequently I have another Chronic Rheumatic Heart Disease with Aortic Regurgitation for emergency Caesarean Section for prolonged second stage. Then followed by many other cases as well such as Fetal Distress, Pre eclampsia with macrosomia; Macrosomia/Big Baby in Labour etc etc.. I also can't remember how many cases I have done altogether...

Have another case with possible Post Dural Puncture Headache (PDPH).. post op Day 1 LSCS. She was quite distressed earlier on with severe headache aggravated by upright posture and relieved by lying down. Explanation given to her and she was asked to Rest In Bed. She was encouraged to take adequate fluid and caffeinated drinks as well.. Intravenous Drip also given to ensure adequate hydration. Pain relief with tablet mefenemic acid/ponstan was given as well.. With these conservative Management, her symptoms was relieved quite fast... I told her as well PDPH most of the time can be treated conservatively but if the headache persist or worsening, epidural blood patch need to be performed..

I'm on call again tomorrow.. Hope tomorrow will be a better day :)