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

Hi Everyone,

This week Matt and I agreed to get together to do another journal club episode (or more accurately I printed out an article, put it in Matt's pigeon hole and told him to make himself available or else!).

We went to one of our favourite journals IJOA (International Journal of Obstetric Anesthesia), where we chose an article from the latest edition published in May.

The article is entitled "A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard Ostheimer lecture."

The background to this article is that every year the north american Society of Obstetric Anesthesia and Perinatology (SOAP) hold an annual conference. One of the highlights of these annual conferences is this lecture which is researched and then presented by a well respected obstetric anesthesiologist from the north american community. The lecture is a narrative review of the previous years published literature highlighting important papers and discussing their importance and relevance particularly in relation to current north american practice.

This year's lecture was presented by Pervez Sultan from Stanford University, and it is drawn from a review of articles published in 2022 from 66 different journals. Over 12 different themes are discussed including (but not limited to) TIVA for GA Caesareans, dexamethasone for post CS analgesia, predicting epidural blood patch success, dural puncture epidurals and a number of other interesting topics.

Join Matt and I as we discuss these and muse over what relevance they may have to our current practice here in Western Australia as well as a couple terrible olympic themed dad jokes to close!

References / Links

A narrative review of the literature relevant to obstetric anesthesiologists: the 2023 Gerard W. Ostheimer lecture  Int J Obstet Anesth 2024 May:58:103973. doi: 10.1016/j.ijoa.2023.103973. Epub 2024 Jan 3.

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.

REFERENCES

NAP7 - Royal College of Anaesthetists

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:

Useful Links / References

https://youtu.be/Jaq-vHbcGi0

https://youtu.be/oMXkGgoRMpE

Cook T, Woodall N, Frerk C, Project FNA. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British journal of anaesthesia. 2011;106(5):617-31.

Kei J, Mebust DP. Comparing the effectiveness of a novel suction set-up using an adult endotracheal tube connected to a meconium aspirator vs. a traditional Yankauer suction instrument. The Journal of emergency medicine. 2017;52(4):433-7.

Andreae M, Cox R, Shy B, Wong N, Strayer R. 319 Yankauer outperformed by alternative suction devices in evacuation of simulated emesis. Annals of Emergency Medicine. 2016;68(4):S123.

Cox R, Andreae M, Shy B, DuCanto J, Strayer R. Yankauer suction catheters with “safety” vent holes may impair safety in emergent airway management. The American Journal of Emergency Medicine. 2017;35(11):1762-3.

Nikolla DA, King B, Heslin A, Carlson JN. Comparison of Suction Rates Between a Standard Yankauer, a Commercial Large-Bore Suction Device, and a Makeshift Large-Bore Suction Device. The Journal of Emergency Medicine. 2021;61(3):265-70.

Weingart SD, Bhagwan SD. A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation. Journal of clinical anesthesia. 2011;23(6):518-9.

Han S, Fisher JA. Airway Management During Persistent Flooding Of the Oropharyngeal Airway.

DuCanto J, Serrano KD, Thompson RJ. Novel airway training tool that simulates vomiting: suction-assisted laryngoscopy assisted decontamination (SALAD) system. Western Journal of Emergency Medicine. 2017;18(1):117.

Root CW, Mitchell OJ, Brown R, Evers CB, Boyle J, Griffin C, et al. Suction Assisted Laryngoscopy and Airway Decontamination (SALAD): A technique for improved emergency airway management. Resuscitation Plus. 2020;1:100005.

Chrimes N. The Vortex: a universal ‘high-acuity implementation tool'for emergency airway management. BJA: British Journal of Anaesthesia. 2016;117(suppl_1):i20-i7.

Finke S-R, Schroeder DC, Ecker H, Böttiger BW, Herff H, Wetsch WA. Comparing suction rates of novel DuCanto catheter against Yankauer and standard suction catheter using liquids of different viscosity—a technical simulation. BMC anesthesiology. 2022;22(1):285.

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).

Useful References

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

https://litfl.com/hyperkalaemia-ecg-library

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.

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

References

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!

You recline your seat back, adjust your neck pillow, eye mask and close your eyes. Finally you are about to have that well earned nap. It was exhausting having to get up at 3am to head to the airport for this unpleasantly scheduled early flight. As your mind drifts towards sleep your thoughts are interrupted by a loud announcement by one of the cabin crew.

"If anyone with medical experience is onboard can you please make yourselves known to the cabin crew?"

You gently pull your mask aside and see two cabin crew applying oxygen and crouching over a passenger lying supine at the front of the aircraft. You quietly glance around the aircraft - no one else seems to have volunteered to help........

If you have any medical, nursing or paramedical training and you occasionally fly on an aeroplane then this talk could well be relevant to you!

This week I am joined by Ilan, one of our anaesthetic fellows and the current education fellow. Ilan is also a licensed pilot and has an interest in inflight medical emergencies and their management. Join us as we discuss the physiology, epidemiology, legal issues and share some anecdotes on this fascinating topic.

Thanks Ilan!

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789915/ - In flight medical emergencies Western J Emerg Medicine 2013

https://jamanetwork.com/journals/jama/article-abstract/2719313 - In flight medical emergencies JAMA 2018

https://onepagericu.com/in-flight-medical?rq=flight -

https://www.casa.gov.au/ - Australian Aviation Governing Authority where all the legal requirements for flight operations in Australia can be found

https://insightplus.mja.com.au/2017/39/what-is-my-duty-to-assist-in-emergency/ - Duty to Assist in MJA

https://www1.racgp.org.au/newsgp/professional/medical-good-samaritans-and-the-law-what-gps-need

You are called to review a woman in labour ward. When you arrive you are told her epidural is no longer working. The epidural was placed by a colleague 5 hours ago and was working well. However in the last 20-30 minutes she has developed breakthrough pain despite a top up and pressing the PCEA a few times. You look at her back and the epidural dressing looks fine - no obvious explanation there.

Upon further questioning you are told that she had a caesarean in her previous pregnancy and she is attempting a VBAC. She tells you that since you arrived in the room the pain has changed. Now it is constant and she has developed pain in her shoulder. Suddenly the CTG deteriorates and within a few minutes the team are calling a code blue caesarean to theatre.....This is recollection of a real case from an evening shift a few years ago.

As you can probably guess this week we are discussing the important and somewhat scary topic of uterine rupture.

This week we are joined to discuss this topic by Dr David Owen. David is a senior obstetrician, who previous to WA worked at Liverpool Women's Hospital and was a psychiatrist in a previous life.

Thanks David!

References

Uterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India

Tocogram characteristics of uterine rupture: a systematic review

A maternal death is always a tragic event for the mother, the child, the family and society at large. Unfortunately in some parts of the globe this is still a much too common event. Luckily for those of us living in higher resource countries it has now become relatively rare.

This week Matt and I sat down together to discuss the history of maternal mortality reporting, and all the useful knowledge we have been able to learn over the years from these important resources.

What are direct, indirect and coincidental maternal deaths? We touch on some aspects of the recent Australian reports and then go into depth on the long history of the UK reports which have many strengths such as their national funding, compulsory reporting, anonymous nature and very long history.

Thanks Matt

References

Maternal Mortality Report Australia

Maternal Mortality World Health Organisation WHO

MBRRACE-UK Maternal mortality reports UK

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