Myometrial Injection of Vasopressin

1. Myometrial Injection of Vasopressin Verna Thomas, BSN, SRNA

2. Objectives • Familiarize learner with myomectomy procedure and management options • Describe anesthetic considerations for myomectomy • Identify purpose for use of vasopressin and mechanism of action • Recognize potential complications associated with use of vasopressin • Engage the learner in a spirited discussion regarding a case of myometrial vasopressin injection

3. Case of Interest • 29 y/o AA Female, • 67 kg • ASA 2, MP II • Employed RN • History of uterine fibroid, syncope at work, received cardiac work-up, anemic • Robotic Assisted Laparoscopic Myomectomy

4. Myomectomy • Define most common benign tumor of the uterus in women of reproductive age • Prevalence clinically diagnosed in 25% of women with a predicted incidence of 75% • Rationale myomectomy versus hysterectomy to preserve fertility • Population predominance amongst African American women of child-bearing age to ~ 50y

6. Management Options • Uterine Artery Embolization

7. Management Options • Laparoscopic Assisted Abdominal Myomectomy (LAAM) • Laparoscopic Myomectomy (Standard)

9. Robot Assisted

10. Anesthesia Considerations • Bleeding • Hemodynamic Alteration • Respiratory Compromise • Positioning

11. Myoma Blood Supply

12. Case Update #1 • Standard Induction • Trocars/Insufflation • Vasopressin Injection • Re-insufflation

13. Traditional Use

14. Endogenous Synthesis

15. Effects

16. Synthetic Vasopressin in Myomectomy • Control bleeding • Potent vasoconstrictor • 20U/ml diluted in 100-200ml of NSS • Max injection 3-5U • Anesthesia should be notified before injection • Aspirate before injection • 15-25 min half-life

17. Medical Templates 2003 Template 8 20 units in 200ml NS Max 3-5 units

18. Case Update #2 • Robotic Assisted Laparoscopic Myomectomy • Approximately 45-60 min into the case • Incision through serosa • BP cuff cycling every 3 minutes

19. Series of Unfortunate Events

20. Differential Diagnosis • Venous Air Embolism (VAE) • Subatmospheric pressure w/i an open vein • Decreased EtCO2, desaturation, sudden hypotension • TEE, precordial Doppler sonography • Pulmonary Embolus • Entry of blood clots, fat, tumor cells, air, amniotic fluid, or foreign material into venous system • sudden cardiovascular collapse, hypoxemia, bronchospasm, decreased ETCO2, elevated CVP and PAP • TEE; may not reveal the embolus but will show R. heart distension and dysfunction • MI • No preoperative comorbidities • HoTN, bradycardia, no detectable ECG changes • TEE; more sensitive indicator of MI than ECG • Hemorrhage

21. Transesophageal EchocardiogramAkinesis *

22. Transesophageal EchocardiogramNormal *

24. Case Update #3 • Weak/thready carotid pulse • Absent radial pulses • PEA w/ACLS • Central line placement • Swan ganz placement • Milrinone and Epinepherine infusion • Pulmonary Edema • Lasix • Refractory hypoxemia

25. Case Conclusion • Prepped for ECMO • Heparinized • Near Complete Resolution • Balloon Pump • Following Commands • Pressors and balloon pump discontinued • Discharged from hospital POD 8

26. What Did We Learn Vigilance • Never deviate from standard of care • Treated the BP • Notified the surgeon and called for help • Rapid assessment and treatment/supportive care

28. Questions/Comments