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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As the duty anaesthetist you are called down to the antenatal clinic by the obstetric team to see a pregnant woman with achondroplasia who is booked to deliver in your hospital.

What are the anaesthetic issues which can arise in this condition? What evidence is there in the literature for the optimal anaesthetic techniques? What will you discuss with this woman and how will you counsel her?

Join Declan and I as we discuss the anaesthetic issues of this relatively rare but sometimes challenging condition...

References

Dumitrascu CI, Eneh PN, Keim AA, Kraus MB, Sharpe EE. Anesthetic management of parturients with achondroplasia: a case series. Proc (Bayl Univ Med Cent). 2023 Dec 20;37(1):63-68. doi: 10.1080/08998280.2023.2261084. PMID: 38173994; PMCID: PMC10761160.

Lange, E.M.S., Toledo, P., Stariha, J. et al. Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism. Can J Anesth/J Can Anesth 63, 945–951 (2016). https://doi.org/10.1007/s12630-016-0671-5

15 Ways Pregnancy Is Different For Little People - Good Lay Person Website

You are called to a code blue on the postnatal ward. A 28 yr old female who is 1 day post a non elective caesarean section has just had a witnessed convulsion lasting 1-2 min. She has now regained consciousness but seems a little confused and is complaining that she "has lost vision in both of her eyes". Her BP is 180/100, and all other vital signs are normal.

What is this most likely to be? What is your differential diagnosis (what things do you not want to miss)? What investigations would you like done?

This turns out to be an episode of eclampsia and PRES (posterior reversible encephalopathy syndrome).

What is PRES? What are it's radiological features and what is the mechanism which leads to this disorder?

Join Graeme and I as we discuss this uncommon but fascinating condition.

References

Gewirtz AN, Gao V, Parauda SC, Robbins MS. Posterior Reversible Encephalopathy Syndrome. Curr Pain Headache Rep. 2021 Feb 25;25(3):19. doi: 10.1007/s11916-020-00932-1. PMID: 33630183; PMCID: PMC7905767.

Marcoccia E, Piccioni MG, Schiavi MC, Colagiovanni V, Zannini I, Musella A, Visentin VS, Vena F, Masselli G, Monti M, Perrone G, Panici PB, Brunelli R. Postpartum Posterior Reversible Encephalopathy Syndrome (PRES): Three Case Reports and Literature Review. Case Rep Obstet Gynecol. 2019 Jan 27;2019:9527632. doi: 10.1155/2019/9527632. PMID: 30809401; PMCID: PMC6369475.

Hi everyone,

Join us this episode - Declan and I have scoured the literature for a few interesting articles of varying degrees of quality! We had fun discussing these articles and hopefully you will also enjoy our discussion.

Hopefully we will make this a regular feature every 3-4 months!

Articles Discussed

1 - Effect of Dural-Puncture Epidural vs Standard Epidural for Epidural Extension on Onset Time of Surgical Anesthesia in Elective Cesarean DeliveryA Randomized Clinical Trial

In this RCT published in JAMA - the time to surgical anaesthesia was 4 min faster when topping up a dural puncture epidural in comparison to a standard epidural catheter.

2 - Neuraxial buprenorphine for post-cesarean delivery analgesia: a case series

This correspondence from the International Journal of Obstetric Anesthesia (IJOA) this year discussed the experience of a small hospital which decided to use neuraxial buprenorphine when there was a morphine shortage.

3 - There's No Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment

This classic paper from 2006 is a must read for anyone who is involved in debriefing and simulation in healthcare.

4 - Improving blood product management in placenta accreta patients with severe bleeding: institutional experience

This short report from IJOA 2023 describes the experience of blood product management in patients with placenta accreta spectrum disorder in a large tertiary referral hospital in Israel.

5 - Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study

This observational study from Analgesia & Anesthesia 2022 examined 70 women with severe PET with lung ultrasound and ECHO to assess diastolic dysfunction.

You are called to labour ward to place an epidural in a nulliparous woman who is obviously extremely distressed in pain. After you sit her up to clean her back you notice she has a long scar running down the middle of her back. Between contractions she tells you she had surgery as a teenager to straighten her back.....what does this mean?

Hi Everyone,

Graeme regularly teaches this topic to our anaesthesia trainees and I was surprised to realise that we haven't done a podcast on this already. Join us as we discuss scoliosis, spina bifida, spinal surgery and other assorted spinal issues.

TRAGIC CASE OF AIRWAY DEATH DUE TO SEVERE KYPHOSCOLIOSIS - FROM WEST AUSTRALIAN

Hi Everyone,

Whole blood, freeze dried plasma, refrigerated or frozen platelets....

On Oct 31st - Nov 3 Graeme, Emelyn and I attended the THOR - THUNDER conference hosted here in Perth at the Rendezvous Hotel in Scarborough.

Who is THOR? In their own words:

The THOR (trauma haemostasis oxygenation resuscitation) organization is a resuscitation and blood network, originating in Norway a decade ago, and now boasting global reach. It has built an avid following of both civilian and military resuscitation clinicians and scientists, covering both pre-hospital and hospital management of critically unwell patients.

The THOR vision is to improve outcomes from traumatic haemorrhagic shock by optimising the acute phase of resuscitation. The mission is to develop and implement the best practices for haemorrhagic shock resuscitation from pre-hospital care right through to the completion of the acute phase of hospital resuscitation.

Thor group website: Trauma Hemostasis and Oxygenation Research Network (rdcr.org)

We sat down to reflect on the different topics that were presented at this fascinating conference. A big shout out to Tania Rogerson for organising such an amazing bunch of speakers. It was great to hear how resuscitation of major haemorrhage is done in other parts of the globe and to be educated about some different resuscitation products that are not available here in Australia.

If you also want to hear a great deep dive into the scientific evidence base for the management of massive haemorrhage then I highly recommend listening to Casey Parker and Justin Morgenstein discussing this topic here (thanks for a great balanced summary of the evidence):

Massive Haemorrhage: Science and Practice - Broome Docs - Nov 2023

Massive hemorrhage: a very deep dive - First10EM - Nov 2023

References

Evaluation of freeze dried plasma for use in NSW - https://aci.health.nsw.gov.au/networks/trauma/resources/freeze-dried-plasma

There has even been a pilot study comparing whole blood for use in accrete spectrum surgery in San Antonio:

Whole blood transfusion reduces overall component transfusion in cases of placenta accreta spectrum: a pilot program.J Matern Fetal Neonatal Med 2022 Dec;35(25):6455-6460.

The Use of Whole Blood Transfusion in Trauma - Curr Anesthesiol Rep Jan 2022

Warming Up to Cold-stored Platelets Anesthesiology December 2020, Vol. 133, 1161–1163.