Intraoperative use of point of care ultrasonography (POCUS) for stat cesarean delivery with refractory hypoxemia

A 30-year-old female at 24 weeks gestation presented with headache, hypertension and blurry vision. She was diagnosed with pre-eclampsia on chronic hypertension. An obstetrical emergency was called due to fetal heart rate decreasing to a nadir of 40bpm and the patient was taken for an emergent cesarean delivery. Prior to induction of anesthesia, the SpO2 was 92%. A rapid sequence induction was conducted with confirmed intubation however, SpO2 decreased to 71% over time. The patient was ventilated manually and was given bronchodialators. However, oxygenation did not improve. A portable point-of-care ultrasound (POCUS) device was brought into the operating room. Windows obtained suggested that the patient had gross pulmonary edema resulting from begining cardiac failure. Given the findings, 1:1 crystalloid replacement was undertaken rather than the traditional 3:1 replacement for crystalloid to blood loss ratio. Blood pressure was reduced with medications including volatile agents. The patient’s SpO2 slowly improved and by the end of the surgical procedure. Re-imaging of the pleural views revealed improvement of interstitial pulmonary fluid. The patient remained intubated post-operatively. The patient was extubated on POD 2 and eventually discharged home. Peri-operative POCUS was used to help aid in a diagnosis of an emergent cesarean delivery with ongoing hypoxia. Multiple disciplines including obstetrics, anesthesia and critical care were able to visualize her problems and collaborate with plan for management and post operative care.