Hi everyone,

This week Declan and I sit down to discuss a novel non opioid analgesic drug recently approved for use by the FDA, suzetrigine.

What is it? How does it work? Why should we be interested in this new class of drugs and most importantly will it live up to it's hype?

References

Suzetrigine: First in a New Class of Nonopioid Analgesics for Acute Pain. Anesthesiology 142(6):p 989-991, June 2025. | DOI: 10.1097/ALN.0000000000005465 - Unfortunately this is not a free article but well worth a read if you can get to it through your hospital or college library. The accompanying podcast of this editorial is open access - follow the following link. podcast

Suzetrigine Drug-Drug Interactions: Perioperative Anesthesia Considerations to Enhance Patient Safety

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.

You are called to assess a pregnant woman who presents to your hospital complaining of shortness of breath. She is 36 weeks pregnant with twins and tells you she had been getting progressively short of breath over the last month but put it down to the physical effects of the twin pregnancy in her abdomen. However last night she couldn't get her breath lying flat, had to sleep sitting up on 3-4 pillows and feels that "it is much worse". On examination she has a respiratory rate of 24/min, SpO2 = 92%, HR 105/min, BP 95/45 and you can hear crepitations in both lung fields. Her initial blood tests come back showing a raised plasma BNP and a bedside ECHO is done by a helpful colleague - who says "subjectively her LV isn't contracting very well".

Hi everyone,

This week I sit down with Dr Faith Njue the most qualified person here in WA to discuss the rare but important disease - peripartum cardiomyopathy. (See Faith's Bio below).

Join us in our wide ranging discussion which touches on the diagnostic challenges, demographics, proposed mechanisms and general principles involved in managing these complex patients.

Thanks Faith for a great discussion!

Dr Faith Njue - Bio

Faith Njue graduated from the University of Western Australia and completed cardiology training in Perth. She undertook further subspeciality training in advanced heart failure/ heart transplantation at Fiona Stanley Hospital and the University of Ottawa Heart Institute in Canada. Thereafter, she undertook further fellowship in cardio-obstetrics at the John Radcliffe hospital in Oxford (UK).

She has special interest in women’s cardiovascular health, heart disease in pregnancy and heart failure. Faith runs the dedicated Western Cardiology cardio-obstetrics clinic, designed to support women at risk of or with pre-existing heart conditions, through preconception counselling, pregnancy and into the post-partum period. Cardio-obstetrics is an expanding subspecialty that focuses on prevention, early detection, and appropriate management of cardiovascular disease in pregnancy.

She holds public consultant positions at Sir Charles Gairdner and Fiona Stanley hospitals. She is part of the Advanced heart Failure and Cardiac Transplant team at FSH. She is the cardiology clinical lead for High Risk pregnancy at FSH.

References

Anaesthesia and peripartum cardiomyopathy Chapman, K. Njue F, Rucklidge M. BJA Education, Volume 23, Issue 12, 464 - 472

Melanie Ricke-Hoch, Tobias J. Pfeffer, and Denise Hilfiker-Kleiner. Peripartumcardiomyopathy: basic mechanisms and hope for new therapies. Cardiovascular Research (2020) 116, 520–531. doi:10.1093/cvr/cvz252​

Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail. 2019 Jul;21(7):827-843. doi: 10.1002/ejhf.1493. Epub 2019 Jun 27. PMID: 31243866​

2018 ESC Guidelines for the Management of Cardiovascular Disease During Pregnancy. European Heart Journal 2018. Vol 39;3165-3241​

Bromocriptine:

Koenig T, Bauersachs J, Hilfiker-Kleiner D. Bromocriptine for the Treatment of Peripartum Cardiomyopathy. Card Fail Rev. 2018 May;4(1):46-49. doi: 10.15420/cfr.2018:2:2. PMID: 29892477; PMCID: PMC5971672

Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J. 2017 Sep 14;38(35):2671-2679. doi: 10.1093/eurheartj/ehx355. PMID: 28934837; PMCID: PMC5837241.

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!

References

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

https://youtu.be/bYIPkNfPDUI

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:

Surgical management - team members, techniques and approach

Techniques for catastophic bleeding - manual aortic compression, vascular clamping, interventional radiology

Postpartum issues

Controversies (ICU vs HDU, leaving placenta in -situ)

Thoughts for the future

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

References

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

Hi Everyone,

This week I had the privilege of sitting down and recording two fascinating episodes with two of the founding members of the Placenta Accreta Spectrum Team from here at KEMH, Dr Matt Epee-Bekima and Dr David Owen. In this first episode we discuss the following:

Definitions and pathology of placenta accreta spectrum

What is the story behind the formation of the PAS team?

Screening / Identification / Diagnosis and referral

The optimisation and planning of the patient's journey.

References

King Edward Memorial Hospital website - The Placenta Accreta Spectrum guideline

Hi Everyone,

Join Graeme and I as we discuss two articles chosen from last months edition of IJOA (International Journal of Obstetric Anesthesia). In the first we discuss an article exploring whether the use of intermittent calf compression can reduce hypotension and vasopressor use in women undergoing caesarean section under spinal anaesthesia. The second article looks at the utility of preoperative electrical stimulation of acupressure points prior to caesarean section reduces postoperative pain and improves the quality of maternal recovery. There's a sprinkling of our usual dad jokes at the end.

For regular listeners to the show join us again later this month when we hopefully will have a couple of episodes dedicated to the management of placenta accreta spectrum and an interview with the founders of the placenta accreta service setup 7 years ago here at KEMH - see you then!

References

International Journal of Obstetric Anesthesia

Effect of pneumatic leg compression on phenylephrine dose for hypotension prophylaxis via variable rate infusion at cesarean delivery: an unblinded randomized controlled trial

Transcutaneous electrical acupuncture point stimulation and quality of recovery following cesarean delivery: A randomized controlled trial

The next patient on your elective list arrives in theatre. She is a 35 year old woman booked for hysteroscopy to investigate her menorrhagia. She has no co-morbidities so wasn't seen preoperatively in a clinic. She tells you that she has no medical problems but did start on Wegovy for weight loss about 4months ago and has now lost about 12kg. She hasn't eaten anything since 9pm last night - it is now 10am. You were planning a general anaesthetic and a supra-glottic device, but now you're not sure what you should do?

Hi everyone,

This week I am joined by Erin and we discuss in detail the perplexing topic of GLP1 receptor agonists. These new wonder weight loss drugs seem to be all the rage and certainly things look rosy if you have shares in Novo Nordisk (the manufacturer). However they are not so great if you provide anaesthesia.... We discuss their relationship with delayed gastric emptying and the risk of aspiration.

References

ANZCA GLP1 clinical practice recommendation June 2024

ASA consensus based guidance on preoperative management of GLP1 agonists Feb 2024

Gastricultrasound.org. - This is the best resource available (our humble opinion) if you want to upskill yourself to be able to assess the contents of the stomach.

ANZCA clinical practice recommendation summary - June 2024 see below

Your patient arrives in the anaesthetic room next to theatre, she's booked for a non elective caesarean for failure to progress. She has an epidural in situ and you decide try to top it up - however after 25ml of lignocaine 2% with adrenaline and around 20min of waiting the block is stuck at the umbilicus and she can still move her legs relatively freely. This is obviously not going to be adequate - she is adamant she wants to be awake to see her baby born. You sit her up, pull out the epidural and do a single shot spinal with 2.1ml of heavy bupivacaine 0.5% + fentanyl 15mcg - after all you don't want this block to fail as well!

You clean her back, lie her down and turn to talk to the midwife. When you turn back to the patient 30s later she looks a little purple and isn't breathing.......

Hi everyone join Graeme and I this week as we discuss total spinal anaesthesia - a fascinating but somewhat scary rare emergency which can occur when we use regional anaesthesia in obstetric practice.

A big shout out to the team from Rotunda Hospital in Dublin who wrote the recent narrative review published in IJOA on this topic!

References

Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review Radwan, M.A. et al.International Journal of Obstetric Anesthesia, Volume 59, 104208

Sobhy S, Zamora J, Dharmarajah K, Arroyo-Manzano D, Wilson M, Navaratnarajah R, Coomarasamy A, Khan KS, Thangaratinam S. Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Glob Health. 2016 May;4(5):e320-7. doi: 10.1016/S2214-109X(16)30003-1. PMID: 27102195.

What is the EXIT procedure? Who is it used for and how do we do it?

In our institution this procedure only occurs on average every 3-4 years. It is an event where a large diverse group of individuals, who often have never met each other, come together for a brief period of time to work as a highly complex team to achieve a great result for both the mother and baby.

Join Lloyd and I as we do a deep discussion on this uncommon but challenging multi-disciplinary procedure.

References

Maternal anesthesia for EXIT procedure: A systematic review of literature.

The management of congenital upper airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure