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After catastrophic event in labor and delivery. Advice needed.From: Gary Kleinman (fuf@gulf.net)Fri Mar 21 19:16:14 1997
I sure could use some help. This is probably out of my (our) hands but any advice would be most helpful. I can't stand to see a mother, wife, daughter and friend of a lot of people remain in a neverending coma without hope of recovery and with permanent brain damage. On St. Patrick's Night, a 32 year old g2p1 gestational diet controlled diabetic presented in early labor with possible ruptured membranes. The pregnancy was complicated by mild edema and no other evidence of preeclampsia. In the lobby, the patient had a grand mal seizure. She was rapidly wheeled up to labor and delivery where she had a second seizure and lost her pulse and respiration. CPR was started and 12 minutes after the arrest, a term baby was delivered, acidotic but recovered. The mother was in electro-mechanical dissociation (I arrived during the c-section and CPR). She was brought back ( to a pulse ) about 15 minutes after the cesarean was completed with several doses of epinephrine and a lidocaine drip. I estimate CPR was done for about 40 minutes. A gas during the latter portion of CPR showed pH 7.1, P02 70 and PC02 30. In the intensive care unit, she was in shock (BP 70/30 pulse 130) with no urine output. Before DIC developed, the patient recieved blood(8 units total), cryo (about 20 units) and ffp (4 u). DIC was controlled and on day one, she only needed platelet transfusions. The shock state was corrected about 4 hours after the arrest, and vasopressors where no longer necessary. Urine output improved. There was no signs of sepsis. Unasyn was given. A Swan Ganz catheter insertion failed (hematomas) and was inserted on day 1, with normal cardiac and wedge pressures. Maternal seizures began on day 1 post arrest. EEG showed diffuse slowing (dilantin and phenobarb were given). CT was normal. A repeat CT is pending. Today, on day 4, the patient is still intubated but improving respiratory-wise (IMV of 6, about 30% FiO2). She still has seizures and posturing. According to the neurologist, she does not respond to verbal or other stimulation except pain (withdrawal). Seizure activity seems most prevalent in the left arm. The family thinks she is showing a conscious response. I seem to think she recognizes voice. The neurologists and nurses think otherwise. Vitals (except respiration) and hematologic parameters are stable. The baby had seizures, controlled on meds and is improving. She (baby) was extubated on day 2. We still dont have an exact diagnosis but amniotic fluid embolus seems most likely. Please! Could anyone help me with any suggestions to help improve long term neurologic outcome? Any way to tell if patient is responding to voice or other subtle stimuli? Maybe I just have to try harder to communicate with her. Thanks for your suggestions.
-- Gary Kleinman
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