Canadian journal of anaesthesia = Journal canadien d'anesthésie
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Shock is defined as a situation where oxygen transport and delivery is inadequate to meet oxygen demand. The patient in shock is evaluated through medical history, physical examination, and careful observation of the hemodynamic and respiratory monitors. The patient is initially managed with basic resuscitation measures, however bedside ultrasound should be performed if hemodynamic instability persists. We propose to use ultrasound of the inferior vena cava (IVC), and the concept of venous return, as the initial step in order to identify the mechanism of shock. Doppler examination of the hepatic venous flow can also be added. Further ultrasound examination of the patient's heart, thorax, and abdomen can then be performed in order to determine the etiology of shock. In patients with reduced mean systemic venous pressure, an examination of the patient's thoracic and abdominal cavities to detect free fluid, pneumonia, or empyema can be considered. In patients with increased right atrial pressure, transthoracic echocardiography will allow identification of left or right ventricular dysfunction. Finally, in the presence of increased resistance to venous return, thoracic examination for pneumothorax or cardiac tamponade and abdominal examination for signs of abdominal compartment syndrome or IVC occlusion can be considered. Subsequent treatment can then be tailored to the etiology of shock. Elements of bedside ultrasound examination are currently taught in many anesthesia training programs. ⋯ To develop an approach to the patient in shock that incorporates bedside ultrasound examination.
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High or total spinal anesthesia commonly results from accidental placement of an epidural catheter in the intrathecal space with subsequent injection of excessive volumes of local anesthetic. Cerebrospinal lavage has been shown to be effective at reversing the effects of high/total spinal anesthesia but is rarely considered in obstetric cases. Here, we describe the use of cerebrospinal lavage to prevent potential complications from high/total spinal anesthesia after unintentional placement of an intrathecal catheter in a labouring obstetric patient. ⋯ We show that exchange of CSF for normal saline can be used successfully to manage a high spinal in an obstetric patient. Our results suggest that CSF lavage could potentially be an important and helpful adjunct to the conventional supportive management of obstetric patients in the event of inadvertent high or total spinal anesthesia.