Hi everyone,

Join us on the podcast where this week we have part 2 of the discussion with Dr Sonya Ting on tips for management of acute perioperative pain. We explore some advice on how to manage a tricky obstetric patient with post caesarean pain issues.

I also failed dismally to entice any responses to last weeks quiz entitled “Anaesthetist or serial killer”. In one final last ditch attempt to rescue this quiz from abject failure I have now rebranded it. I have supplied you with a small crossword which can be used to get some hints as to the name of the individual who is pictured – and then I am guessing using the power of  the internet someone should be able to figure out who this is!

Hi everyone,

This week I am joined again by my colleague Dr Sonya Ting – where I attempt to pick her brains for some useful advice in managing difficult perioperative pain issues. Sonya’s first episode on the opioid epidemic has already taken first place on the podcast download list as the most popular episode so far!

Hypothetical Patient

A 50yr old woman is on your list and scheduled to undergo a laparascopic hysterectomy. You see her in the preoperative area:

Q – What issues / history should you explore to identify if this patient is at risk of perioperative pain issues?

Q – How are you going to explain to her the plan for her perioperative pain management, what are the goals and what strategies fo you use to manage her expectations?

Q – What communication strategies can you use, what about non-verbal and verbal communication?

Listen to Sonya and I discuss these issues on the podcast – and finally have a crack at the latest instalment of our quiz below:

Is the following person an anaesthetist or is he a serial killer (or perhaps is he both!) Massive bonus points available if you can actually name this individual!

You are the anaesthetic consultant on call and you are woken (again) at 2am on a Saturday night by your registrar. They tell you they have been asked by the obstetric team to see a pregnant woman who has just arrived in the hospital contracting with ruptured membranes at 30 weeks gestation and is telling everyone “I only have half a heart”! The registrar tells you they have had a look through what they describe as a very large set of patient notes. They tell you it appears that they have been seen by a lot of specialists in the antenatal period but no-one in the overnight team is exactly sure what the plan is for this woman. She is starting to get quite uncomfortable and is asking for some pain relief. The patient herself is not the greatest help – she has told your registrar that she too is confused and that a final decision on how she is going to give birth hasn’t been made yet – but everyone seems to be really worried about it!

What is the Fontan circulation and what implications does this have for pregnancy, childbirth and anaesthesia / analgesia?

This week I am joined by my colleague Chong to discuss this interesting but very challenging condition. Neither Chong or I consider ourselves to be experts in this condition but we have both come across patients with the Fontan circulation during our careers & we are well aware that we may be expected to look after someone with this condition again!!

Please listen to the podcast – we have tried to distil out the important issues and explain them in a sensible manner. If you notice any errors or disagree with any of our content please let us know in a comment!

Dr Fontan from Bordeaux, first described this palliative surgical procedure in 1971. He sadly passed away at the age of 89 earlier this year (Jan 2018).

ANZ Fontan Registry – A great website!

https://www.fontanregistry.com/

The different types of Fontan procedure:

https://www.fontanregistry.com/the-different-fontan-procedures

Khan Academy Youtube tutorial – Detailed description of the 3 stage surgical creation of a Fontan circulation in child with hypoplastic left heart syndrome:

https://youtu.be/4GUm8ybncWY

Layperson description of the Fontan Heart:

https://www.youtube.com/watch?v=1bMq2eWfyyw

Hi everyone,

This week Graeme and I discuss an interesting case from the past involving a parturient with a partially corrected congenital heart condition who presented a bit of a conundrum in the middle of the night.

Before we get into the case discussion however we unpick the prospects for the football (soccer) world cup and admire the Iceland viking clap. Graeme does a bit of a “trump” when he attempts to bluff his way through our world cup conversation by first deploring the antics of the Italian team attempting to fake fouls and he then even picks the Netherlands to win! – and of course neither of these teams are even at the 2018 world cup! Fake news!

Finally to beef up this relatively short episode we have another quiz. Who is the person pictured below and why are they famous in the world of obstetrics? Once again no prizes but we will give you a mention on the next episode for a bit of brief internet fame!

(*Hypothetical case)

You are a busy gynaecologist working in a large public hospital. You are contacted by a GP on the phone about a young 19yr old patient who you operated on 3 weeks ago – she underwent a laparoscopic ovarian cystectomy. The GP tells you that he referred her to your service for investigation of intermittent pelvic pain about 5 months ago and hasn’t seen her since. They inform you that today she turned up for an appointment asking to get a renewal of her Targin 20mg bd which was prescribed by the inpatient team on discharge and which she has been on for the last 3 weeks since leaving hospital. The GP is not very happy! They inform you ” she still has the same pelvic pain but now I also have to manage a 19yr old who is hooked on a fairly decent dose of opioids!”. They rightly point out that she was a bit depressed before they sent her to you but arguably now she is much worse than she was before and they want to know what you are going to do to help………….

What is the “opioid epidemic”? Is this just an issue for North America?

How relevant is it to us here in Australia?

As health care practitioners what has been our role in contributing to the development of this very serious crisis which is killing more young people than HIV / trauma / guns?

This week I interview Dr Sonya Ting – a consultant in anaesthesia and pain medicine. We discuss the opioid epidemic, how it evolved and what we can do as healthcare practitioners.

(*Hypothetical case)

You are the anaesthetist on for obstetrics and a young woman is rushed from labour ward into your theatre for an emergency caesarean for fetal distress. Your registrar is talking with the patient and so you help with the team time out discussion. The obstetrician leading this asks “can you please give 2g of Cefazolin?”. No worries – you grab the 20ml syringe and give the antibiotics over the next 30seconds whilst you help slide the patient onto the table and you instruct your registrar to start topping up her epidural. Your registrar says “no worries” but then looks confused and turns to ask you “where is my syringe?” With a sudden sickening feeling building in your stomach you look down at the now empty 20ml syringe in your hand. You slowly roll it over to reveal a previously hidden sticker………………….. “bupivacaine 0.5%”

Do you ever use local anaesthetics?

This sort of local anaesthetic misadventure is one of those life threatening scenarios which make most anaesthetists break out in a cold sweat but the truth is this is a topic that everyone who uses local anaesthetics needs to be aware of. Indeed many of the reported cases of this life threatening complication have been local anaesthetics used by surgeons, dentists, and other health care practitioners.

Local anaesthetics are amazing analgesic medications which have  many advantages over analgesics like opioids (we here at obsgynaecritcare are big fans of regional analgesia techniques). However in the wrong dose or route these medications block sodium channels in the heart and brain & can cause lethal CNS and cardiac toxicity.

This week I interview Dr Chris McGrath one of our anaesthesia fellows. We discuss the updated ASRA guidelines for management of LAST. There are now some new considerations to traditional ALS and we detail the role of more specific therapies such as intralipid and ECMO.

Congratulations to Sneha and Jeremy (a close second).

The ABG was of 4 climbers at 8400m just below the summit of Everest & taken from this paper in the NEJM:

https://www.nejm.org/doi/10.1056/NEJMoa0801581

The most hypoxic result was that of Dr Dan Martin an anaesthetist from the UK – hear him being interviewed:  Click here

https://www.topmedtalk.com/the-extreme-everest-oxygen-research-consortium/

The group conducting this research are the Extreme Everest Project – headed by a group of UK investigators with critical care backgrounds. They are hoping this research will help us understand how humans can adapt and cope with hypoxia and that this may translate into common conditions we deal with in the critically ill where patients suffer hypoxic injury.

https://www.xtreme-everest.co.uk/

(*Hypothetical Case)

A 26 yr old woman with a suspected ruptured ectopic pregnancy is rushed to theatre in haemorrhagic shock. The patient has a history of IVDU with a naltrexone implant. The team in the emergency department have been unable to get vascular access. She has a heart rate of 150/min and a BP of 75/45. She is now very distressed and unco-operative from both the abdominal pain but also the repeated painful attempts at vascular access with large needles by lots of different healthcare staff!

Join Graeme and I as we discuss the various different options for gaining vascular access to allow resuscitation, but also induction of anaesthesia so definitive surgery can occur.

We discuss the following various options:

Graeme even discloses that he has trialled unsuccessful sternal intraosseous placement in the past – sounds like an interesting case we should perhaps delve into more detail on at another time!!

Hagen-Pouseille Equation:

Bottom line – shorter and wider bore catheters are better for rapid fluid resuscitation.

The MAC line – note swan sheath, haemodialysis or other large bore central catheters will also work:

A great course to learn emergency procedures for use in trauma care run by the critical care trauma team at The Alfred in Melbourne. Check out their description of vascular access in particular their detailed description of the technique for emergent placement of the large bore MAC line in the subclavian vein.

2. https://emcrit.org/pulmcrit/hemodynamic-access-for-the-crashing-patient-the-dirty-double/

A great discussion on the placement of large bore femoral catheters.

3. The Rapid IJ – Ultrasound guided placement of a peripheral iv cannula in the internal jugular.

https://youtu.be/FjSmbUWXznY

These are ABG’s from four different individuals? What do these represent?

First correct answer gets kudos and a mention on the next podcast!

You are in a peripheral hospital without onsite laboratory support after hours and you are involved in the care of a young parturient with uterine atony who has now bled over 2litres. Although you have called in someone to do some laboratory testing – you know that these results will be at least 45-90minutes away. How likely is it that this woman has become  coagulopathic? What approach should you take in this setting? Should you use empiric coagulation supportive therapy? FFP? Fibrinogen? TXA?

Hi everyone,

This week we have the audio of a great talk Nolan wrote for the obstetric intensive care symposium held in Adelaide earlier this year, and which he then kindly presented to our department in April.

Pregnancy is a procoagulant state and during haemorrhage obstetric coagulopathy is actually relatively rare. The underlying mechanisms are different to trauma and other patient groups and we should use this knowledge to help us in our use of blood product therapy especially when rapid coagulation testing (eg viscoelastic tests like ROTEM) are not rapidly available.

However there are some exceptions to this rule – beware early onset of coagulopathy in women with abruption, HELLP, and AFE!

Obstetric Intensive Care Symposium Adelaide 2018

If you want to watch the video of this talk with it’s powerpoint slides:

https://www.dropbox.com/s/y57pf26ge9mry8g/Obstetric%20coagulopathy%20Nolan%20KEMH%20dept%20talk%20version.mp4?dl=0

This week Graeme and I take on a big topic! (excuse the pun),

You are the anaesthetic consultant on call and you are woken by your registrar at 2am who asks you to come and give them a hand with a difficult patient. They have been asked to come down to labour ward to place an epidural in a supermorbidly obese patient who has arrived and appears to be in established labour. She weighs about 190kg, and has a BMI of over 60. The team have been unable to get intravenous access and they want your help with this too. They are also having trouble measuring her blood pressure accurately because of the shape of her upper arms and she is now getting quite distressed with her pain making it difficult for them to examine her obstetrically and monitor her foetus……..

There are many difficult aspects to managing the supermorbidly obese patients. In this podcast Graeme and I discuss some practical tips / points on how to navigate the difficulties which they can present.

Super morbid obesity is defined as a BMI >50.

We hope you will find some of these tips useful if you ever have to care for these women. This is by no means a comprehensive list of tips and we would welcome any other suggestions for tips / techniques you have personally found useful – let us know in the comments below!

Extra long Tuohy and spinal needles

Large upper arm BP cuff – often doesn’t work well.

Use a standard adult BP cuff placed on the forearm

Epidural positioning device – much safer than using a chair / stool or partners legs

Ultrasound guided intravenous cannula placement – often there is a large vein in the mid forearm directly above the radius.

Tunnelling Epidural Catheters: An editorial discussing tunnelling of epidural catheters to prevent accidental catheter migration and Dr Pavy’s famous 1994 article!

Management of supermorbidly obese parturient with two epidural technique:

Hi Everyone,

Congratulations & kudos Jeremy Hickey who correctly identified that this blood gas was a sample from a unit of stored allogeneic blood, sorry we don’t have any actual prize except for getting a mention on the podcast and the glory of seeing your name in print on the website! (If we have any more quizzes we may have to look into this.) Ryan Juniper also deserves a mention for his post on the facebook page which was also very close.

What is the storage lesion of blood? What is 2,3 DPG? What happens to red cell deformability?

Join Graeme and I for a 15minute discussion around the changes that occur in allogeneic blood when it is stored and why this may affect both it’s function and the undesirable effects this may have on our patients. We also briefly discuss and try to make a case for why salvaging and re-infusing a patients own fresh blood may be a much better option if you can achieve this during surgery – however we will leave a detailed discussion on cell salvage for another episode.

Last weeks blood gas – taken from 23 day old stored allogeneic red cells

Click on these to link to the pubmed article:

1.  Osman N. Salaria, MD, Viachaslau M. Barodka. Impaired Red Blood Cell Deformability After Transfusion of Stored Allogeneic Blood but not Autologous Salvaged Blood in Cardiac Surgery Patients. Anesth Analg. 2014 Jun; 118(6): 1179–1187.

2. Andrew V. Scott, BS, Enika Nagababu. 2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion. Anesth Analg. 2016 Mar; 122(3): 616–623.

3. Xiu Liang Li,1 Peng Dong. Oxygen carrying capacity of salvaged blood in patients undergoing off-pump coronary artery bypass grafting surgery: a prospective observational study. J Cardiothorac Surg. 2015; 10: 126.

4. National Blood Authority video – blood still saving lives but there are risks.