HOCMandPregnancy - Hypertrophic Obstructive Cardiomyopathy...

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1 Hypertrophic Obstructive Cardiomyopathy (Case Presentation) Ashraf Andrawis, MD Norman Bolden, MD Metrohealth medical center- CWRU Department of anesthesiology
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2 History (1) 35 YO Hispanic female, 37 weeks pregnant Presented to OB ward on 02/ 2002 for OB f/u H/O syncope: Pt. Collapsed at home during last pregnancy, required emergency C/S, had complicated postoperative course, required ICU admission and CVP monitoring for 1 week HOCM (IHSS) diagnosed Cardiology recommendation: to avoid future pregnancy and permanent sterilization
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3 History (2) CP and chest heaviness: (like baby sitting on my chest) SOB: when doing household activities and when laying flat (use 3 big pillows or sleeping in a chair) Atypical CP: Required hospital admission X 2 during pregnancy CCU admission (11/01) to R/O (PE / MI), heparin 24 h, negative serial ECG and cardiac enz. And V/Q scan. O/B H/R admission (01/02) to R/O (MI / CHF) Heaviness: of Lt. Shoulder and Lt. Arm with exertion Nausea and palpitations when walking
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4 History (3) PMHx Anxiety HOCM (IHSS) diagnosed 2000 OBHx: 37 Weeks Pregnancy, G6P3023, EDD 02/27/02 PSHx: Ectopic pregnancy 1987 Therapeutic abortion 2000 C- section » 1985 child with spina bifida » 1997 child with heart murmur » 2000 child with heart murmur
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5 Physical V.S: BP 112/67, HR 83, RR 20 Wt: 119 Kg, Ht: 6 Ft HEENT: PEERL, EOMI MP: class 2, TMD 5 cm, mouth opening 3FB, good neck mobility, and own dentition Lungs: CTA B/L Heart: ejection systolic murmur grade 3/6 at Lt. sternal border radiates to the base and the apex, no JVD, no Gallop Neurological: AAO x 3, non focal ASA: class 3
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6 Labs and studies (1) CK-MB = 1.0 Fetal lung maturity = 77.3 CXR: slight cardiac enlargement, no infiltrate 11.6 27 8.7 190 133 4.0 97 4 22 94 0.5
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7
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8 Labs and studies (2) Transthoracic echocardiogram: on 01/24/2002 Left ventricular systolic function: EF 65%, hyperdynamic Right ventricular systolic function: normal Valves: AR: mild MR , PR: trivial PAP: 34/12 Subaortic stenosis with fibrocalcific changes, peak gradient 70 mmHg, mean gradient 41 mmHg Compared to prior study dated 11/08/01 (peak gradient = 90, mean gradient 60)
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9 Chronology Feb. 06, 2002: Preoperative assessments, chart, cardiology consult and echocardiography results reviewed, Anesthesia plan D/W Pt. Feb. 07, 2002 At 09:30 AM, pt to OR, standard 5 ASA monitors applied 18 G IV Line, Right Radial A-line and Right IJ 9 Fr introducer placed, SG catheter placed, + wedge at 49 cm, no complication Defibrillator pads applied to treat possible arrhythmia Left uterine displacement applied Initial VS: BP 130/70 HR 80 CVP 11 PA 22/11 CO 4.6 SVO2 72
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10 Intraoperative Management 12:15 PM: Smooth IV rapid sequence induction with Sux 120 mg, STP 350 mg, ETT # 7 placed, + ETCO 2 & BS B/L IVF bolus + maintenance fluid given to keep CVP ~ 11-15 cmH 2 O Surgery started at 12:22 Maintenance of anesthesia: Enflurane 0.6-0.8, N 2 O Labetalol ,Esmolol, Fentanyl titrated to keep BP ~ 130-140/60-70 and HR ~ 70-90 Total IVF: 3000 cc, EBL: 1200 cc, UOP: 300ml
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This note was uploaded on 12/16/2011 for the course BIOLOGY 101 taught by Professor Mr.wallace during the Fall '11 term at Montgomery College.

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HOCMandPregnancy - Hypertrophic Obstructive Cardiomyopathy...

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