Unresolved post-op tachy in c-section pt.

Specialties CRNA

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I am in L&D, but I am posting here in hopes that I could resolve this problem.

A 17 yr old mother in the early stages of labor, no previous hx, vital signs WNL, received an epidural, and then approx. 10 minutes later was wheeled in for stat c-section due to "non-reassuring fetal heart patterns".

Skin incision was uneventful, but when they got in further, she screamed. The anesthesiologist gives her Versed and Ketamine. The baby was out in 6 minutes, and post-op, her HR was to 135. Two days later, she was still 110's, but they ruled out bleeding, infection, and PE thru cat-scan, and she was sent off the floor to postpartum. Other vitals were WNL, including BP, though her O2 sat hovered around 95 (baseline about 98).

Anyone has any thoughts on this, and the reason for her tachyness? Could this have been related to the versed and ketamine?

btw, the baby had average variability, and the decels, though periodic, and dived from 130's to 80's, were not originally prolonged. The catalyst for the call for stat c/s, was a 3 minute decel with marked variability. She was put her knees and they did scalp stimulation, and then made the call.

Thanks for any input and thoughts.

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I am in L&D, but I am posting here in hopes that I could resolve this problem.

A 17 yr old mother in the early stages of labor, no previous hx, vital signs WNL, received an epidural, and then approx. 10 minutes later was wheeled in for stat c-section due to "non-reassuring fetal heart patterns".

Skin incision was uneventful, but when they got in further, she screamed. The anesthesiologist gives her Versed and Ketamine. The baby was out in 6 minutes, and post-op, her HR was to 135. Two days later, she was still 110's, but they ruled out bleeding, infection, and PE thru cat-scan, and she was sent off the floor to postpartum. Other vitals were WNL, including BP, though her O2 sat hovered around 95 (baseline about 98).

Anyone has any thoughts on this, and the reason for her tachyness? Could this have been related to the versed and ketamine?

btw, the baby had average variability, and the decels, though periodic, and dived from 130's to 80's, were not originally prolonged. The catalyst for the call for stat c/s, was a 3 minute decel with marked variability. She was put her knees and they did scalp stimulation, and then made the call.

Thanks for any input and thoughts.

Could still be on the dry side - I don't see any relationship of the tachycardia to the versed or ketamine.
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What was her estimated blood loss for the section? H&H afterwards? How about her blood pressures and urine out afterwards?

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What was her estimated blood loss for the section? H&H afterwards? How about her blood pressures and urine out afterwards?

Blood loss, H&H, BP, urine output unremarkable. That was the first thing we monitored.

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People don't think about this alot, but wound healing is triphasic with the first phase being an inflammatory phase that induces fever secondary to interleukin (IL-1 IL-6) proliferation.

Fever means the patient will be a little tachy, that along with an average EBL for a C/S sets up the patient postoperatively for an elevated HR with lower saturations.

66F

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Specializes in ER, NICU, NSY and some other stuff.

Are you sure this isn't her NORMAL HR? Just asking because my baseline is around 100.

Also what is her anxiety level, pain level?

I just find sometimes you gotta go back to the beginning. and relook at the obvious. Especially if you are in a teaching facility. Those interns are always looking for some big deferential when it may be nothing big.

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Specializes in NICU.
Are you sure this isn't her NORMAL HR? Just asking because my baseline is around 100.

Also what is her anxiety level, pain level?

I just find sometimes you gotta go back to the beginning. and relook at the obvious. Especially if you are in a teaching facility. Those interns are always looking for some big deferential when it may be nothing big.

I was gonna post the exact same thing. All of it.

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Are you sure this isn't her NORMAL HR? Just asking because my baseline is around 100.

Also what is her anxiety level, pain level?

I just find sometimes you gotta go back to the beginning. and relook at the obvious. Especially if you are in a teaching facility. Those interns are always looking for some big deferential when it may be nothing big.

Good question, but we checked her baseline base on her prenatal care chart, as well as during labor. Her temp spiked briefly to 99.9 tympanic about 2 hours post op - it was resolved in one hour without intervention, but the HR would not go down. She was not in pain or discomfort. She had duramorph.

Thanks to all for trying to figure this out.The only thing unusual was the stat c-section, the quick versed and ketamine administration when she was in pain during the procedure. That's also the problem with residents without much experience - I don't really feel comfortable about their knowledge, being new, I find myself trying work this out alone.

As much as I could be I was very watchful. The resident even jumped on me immediately because she looked at the pad, and said why hasn't anyone been monitoring this? I thought, oh, oh, looked at the pad, and it was NOT soaked. She just had a quick glance, and needed someone and something to blame for the tachy, and had a knee jerk reaction. Not that I care that she snapped at me. I'm only purely academically interested in this, so I can be a better practitioner.

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Specializes in ER, NICU, NSY and some other stuff.

LOL GOmpers. ust been in the situation toooo many times to count wher ewe are working someone up for a PE because they have coughed intil their ribs hurt, etc.

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Maybe she had a short manifestation of hypovolemic shock (not from blood loss but from fluid shift....could there have been any vasodilators or such given to increase perfusion to the baby before the c-section that altered capillary permeability and caused a fluid shift??? or just from post pregnacy DHD??.....did she have any edema??) which wasn't fully resolved so when she recovered non-fully from the shock she was still on the edge of returning to shock, maybe her body was just a little confused and wanted to be on the safe side.... or maybe it was just such a hit to her body that it took her longer to compensate than most people....sounds like I'm giving the body a personality or the ability to reason but it's plausible........:coollook:

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Specializes in Anesthesia.
.......maybe it was just such a hit to her body that it took her longer to compensate than most people....

Yes. Seems like a lot of immediate post-op C-Section moms do exhibit a tach for no apparent good reason. Yes, true, they do often get some ephedrine after an SAB, or show a strong sympathetic response to an ET; yes, they can lose a lot of blood; yes, they may experience a mild transient bacteremia; and, yes, they're often scared, excited, ecstatic, choose your own adjective.

But there is *so much* going on with their physiology right then, so many hormonal and neurohumoral adjustments and adaptations in that immediate period, that sometimes the cause of a tachycardia simply cannot be nailed down or easily explained. Just MHO.

deepz

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