Critical care Archives - obsgynaecritcare

Hypothetical Case:

You finish injecting the spinal anaesthetic for your patient who has come for an urgent caesarean section. She has pre-eclampsia and her blood pressure just before you started was 180/100.

Just after lying down she starts vomiting and unfortunately the non invasive blood pressure cuff is going up and down but not giving you a number – she is shaking and can’t stop moving around. Is she vomiting because of hypotension, should you give her a bolus of phenylephrine? What if she is actually still hypertensive – you don’t want to push her BP over 200. Wouldn’t it be great if you had a beat to beat continuous display of her BP – maybe you should have placed an arterial line before starting. Are there any other options that might have been helpful???

Hi everyone,

This week I am joined by John to discuss continuous non-invasive blood pressure monitoring. Many of these technologies have actually been around for a number of years now, but despite this don’t seem to be in commonplace usage. There does seem to be a recent renewed interest in re-evaluating these technologies. How do these technologies work? How accurate are they? Have there been any improvements? What are the economics and costs?

Thanks John for all your hard work researching this topic!

Enhancing Patient Safety with Continuous Blood Pressure Monitoring – APSF (Anesthesia Patient Safety Foundation Newsletter 2026)

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Hypothetical Case:

You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service)

She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders

She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight.

The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea.

Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1

Her bloods are relatively normal except for an unexpected high BNP.

You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension. 

The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia…………………

Hi Everyone,

This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia.

This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them.

Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below:

Australasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End”

Oral vaccine could prevent rheumatic heart disease in NZ

VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease

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Hi everyone,

Sepsis is an important cause of mortality and morbidity in our patients. It is common but can be difficult to diagnose, challenging to manage and sometimes downright scary.

After being inspired by listening to an episode from “The Critical Care Commute Podcast” (with Dr Mervyn Singer a UK intensivist involved in sepsis 3.0), Graeme and I sit down to discuss some of these thought provoking areas of sepsis which are controversial and are still actively being researched.

Thanks again Graeme!

The Critical Care Commute Podcast

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Hi Everyone,

This week I sat down with Declan to discuss a fascinating therapy which is used in many areas of medicine.

This podcast has a bit of everything, a quiz, a part one viva, dubious animal experimentation, discussions about laxatives, and even some references to cosmology and the Big Bang.

Thanks Declan for another entertaining episode.

The post 143 Magnesium in medicine with Declan appeared first on obsgynaecritcare.

Hi everyone,

This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion – an acute obstetric emergency. Luckily this condition is relatively rare – however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals.

Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required!

Thanks again David for your research and preparation for this episode!

Uterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 – 112

Unfortunately (as of Feb 2025) this article is not yet open access – but it is very good if you can get it through your hospital or college library..

Uterine Inversion for the layperson – Cleveland Clinic

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Hi Everyone,

Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 – and has now cared for over 75 women with PAS – including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into:

Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years.

https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0

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Hi everyone,

This week I sit down with Jacob one of the provisional fellows in our department and we discuss the findings from the latest UK National Audit Project – NAP7 – which this time investigated Perioperative cardiac arrest.

NAP7 – Royal College of Anaesthetists

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A woman collapses with abdominal pain in a restaurant & then the initial evaluation in the ED she is diagnosed with suspected ruptured ectopic pregnancy. She is brought straight into your theatre and you perform a rapid sequence induction. You place your video laryngoscope into her mouth and all you see is vomitus and fluid, your yankauer sucker is blocked with food and doing nothing…………

Hi everyone,

This week I am joined by Dr Nathan Blakely one of our enthusiastic trainees to discuss an area he has taken a personal interest in —- the management of the soiled airway.

Thanks Nathan!

Blood in Airway:

The post 132 The soiled airway with Nathan Blakely appeared first on obsgynaecritcare.

As the DA you are paged to come to PACU to review a patient with pre-eclampsia who has just had a PPH and a repair of a perineal tear after delivering in labour ward. The O&G team ordered a VBG because she was febrile and they want to assess her lactate and start her on some antibiotics. The O&G registrar is concerned however because her potassium / K has come back as 7.8 mmol/L….

Join Natalie and I as we discuss the issue of hyperkalaemia specifically in the context of women suffering from pre-eclampsia. Why are they at risk of this important electrolyte abnormality and what are the principles of management?

We also review a recent paper addressing some of the myths surrounding the treatment of acute hyperkalaemia (thanks to Casey at Broomedocs.com for bringing this paper to our attention).

Gupta AA, Self M, Mueller M, Wardi G, Tainter C. Dispelling myths and misconceptions about the treatment of acute hyperkalemia. Am J Emerg Med. 2022 Feb;52:85-91. doi: 10.1016/j.ajem.2021.11.030. PMID: 34890894

LITFL, ECG library, Hyperkalaemia

A case of probable labetalol induced hyperkalaemia in pre-eclampsia. https://pubmed.ncbi.nlm.nih.gov/25370900

Hypocalcaemia and hyperkalaemia during magnesium infusion therapy in a pre-eclamptic patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4614650

Oh’s Intensive Care Manual. 7th Edition. Chapter 93 – Fluid and Electrolyte Therapy. Bersten A, Soni N et al. 2014.

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You receive a page from labour ward.

A woman at 35/40 weeks gestation has just arrived in the hospital very distressed in a lot of pain. A quick bedside ultrasound by the obstetric team has unfortunately demonstrated a large abruption and fetal death in utero. She is contracting strongly and beside herself in pain, the team would like you to come down and place an epidural for analgesia. The team are hoping she will deliver vaginally in the next few hours.

What is your approach in this situation?

Join Graeme and I as we discuss this complex and challenging clinical condition and the coagulopathy that can occasionally occur.

Here is a link to cases we have had in the past here at KEMH in the ROTEM Real Cases Discussed section:

Case 6 – Abruption and fetal death in utero

Case 11 – Abruption and severe coagulopathy

Coagulopathy and placental abruption: changing management with ROTEM-guided fibrinogen concentrate therapy 2015 Liverpool Womens Hospital – this is not open access but available through the ANZCA library or your hospital library. It contains 4 very interesting case reports

Fibrinolytic and thrombotic DIC an explanation 2023 – This paper explains how there are two types of DIC one predominantly causing microvascular thrombosis and eventually factor depletion. The second which is possibly the mechanism seen in some abruptions is massive activation of fibrinolysis and fibrinogenolysis. WARNING this paper is highly technical!

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