Hi everyone,

Welcome to part 1 of a 3 part series we have put together – 3 hypothetical cases involving anaemia / patient blood management scenarios. Thanks to the two great colleagues who made these discussions with me, Dr Anastazia Keegan Head of Haematology here at KEMH and Assoc Prof Nolan McDonnell a colleague from our Department of Anaesthesia.

These cases might sound familiar to any registrars who have attended the Thursday teaching run here over the last 8-9 years!

We had a lot of fun discussing these three cases and I hope there is a lot of great learning for those of you listening – thanks Anastazia and Nolan for giving up a few hours to put these together!

Safety of Intravenous Iron Following Infusion Reactions Stojanovic et al The Journal of Allergy and Clinical Immunology: In Practice Volume 9, Issue 4, April 2021: 1660-1666 – A great paper discussing the different types of reactions to i.v. including the Fishbane reaction and how they were managed in over 13000 iron infusions at the Alfred Hospital in Melbourne. Unfortunately it is an Elsevier publication and you will need some sort of institutional access to read it in full.

You are phoned and asked to review the venous blood gas from a woman who has just given birth in labour ward. She had a long and difficult labour and eventually required an instrumental delivery. The RMO tells you also that she was very difficult to take blood from and the tourniquet was on her arm for quite a long time. Her results show that she has a lactate of 2.5.

Does this result mean she has maternal bacterial sepsis? Does this mean she is in shock, not perfusing her organs properly and they are using anaerobic metabolism? Unfortunately it’s not that simple but these are common misconceptions that we might encounter when interpreting raised lactate levels.

What is lactate? How does the body handle it? What are the different conditions which can raise your lactate levels? If you want to know this and more listen in to our fascinating discussion this week.

Hi everyone,

This week I am joined by two new guests, Tim Marmion one of our talented junior registrars and Declan Sharp the new education fellow here at KEMH. This week Tim kindly agreed to give us a talk he recently wrote whilst working in ICU, on the challenges of lactate interpretation. I cornered him after the talk and he kindly agreed to share it with us on the podcast. Thanks Tim and Declan for a fascinating and educational topic!

How should we interpret lactate in labour? A reference study S.Dockree et al BJOG. 2022 Dec; 129(13): 2150–2156.

Blood Lactate Measurements and Analysis during Exercise: A Guide for Clinicians Matthew Goodwin et al J Diabetes Sci Technol. 2007 Jul; 1(4): 558–569.

Hi Everyone,

“Three minutes after the administration on the spinal anaesthetic they became restless and complained of severe pain in both lower limbs and back. Their heart rate and blood pressure increased to 130bpm and 160/100 mmHg. A rapid survey of previously administered medications revealed tranexamic acid 300mg was accidentally injected into the subarachnoid space instead of 15mg of hyperbaric bupivacaine.” – case report 2021

Graeme and I sit down to do a deep dive on the serious topic of accidental neuraxial administration of tranexamic acid which may have up to 50% mortality. We discuss two papers which summarise over 40 published case reports of spinal administration and one case report of accidental epidural administration. Join us as we discuss the pharmacological mechanism of toxicity, proposed treatments and methods to minimise the risk of this occurring in the first place.

Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. S. Patel, B. Robertson, I. McConachie Anaesthesia. 2019 Jul;74(7):904-914. – Open access

Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia: A narrative review of 22 recent reports. S. Patel Eur J Anesthesiol 2023 May 1;40(5):334-342. – This article is not open access.

Accidental administration of tranexamic acid into the epidural space: a case report. C. Pysyk, L Filteau Can J Anaesth 69, pages 1169–1173 (2022) – open access

Tranexamic acid-associated seizures: Causes and treatment. I.Lecker et al. Ann Neurol 2016 Jan;79(1):18-26.

Hi Everyone,

Join Siv and I as we sit down to discuss a couple of interesting obstetric related topics. The first is the pharmacology around the choice and strength of local anaesthetics used in epidural analgesia – thanks Siv. The second part we discuss a very large pragmatic study in the New England Journal of Medicine of 11000 women studying the use of tranexamic acid as a prophylaxis during caesarean surgery (elective and emergency). Spoiler alert it didn’t show any difference (death or transfusion).

Thanks Siv!

Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery Pacheo et al N Engl J Med 2023; 388:1365-1375

Minimum local analgesic concentration of local anaesthetics. Malachy Columb, Iain Gall Continuing Education in Anaesthesia Critical Care & Pain, Volume 10, Issue 4, August 2010, Pages 114–116

Determination of the Minimum Local Analgesic Concentrations of Epidural Bupivacaine and Lidocaine in Labor. Columb, Malachy O. FRCA; Lyons, Gordon FRCA. Anesthesia & Analgesia 81(4):p 833-837, October 1995.

Hi Everyone,

This week we are joined by Dr Anastazia Keegan an obstetric haematologist and the head of Haematology at our Women’s hospital here in Western Australia. Join us as Anastazia educates us about congenital bleeding disorders in pregnancy – the common ones, Von Willebrands disease and haemophilia – and how to approach a woman with one of the many uncommon ones (which working in a tertiary referral centre are more common than you would expect).

Thanks for all the great advice and insights – we look forward to having Anastazia back in the near future for the lowdown on some more really important haematological conditions we encounter in women’s health.

Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210 (7):

Online Bleeding Assessment Tool ISTH-BAT

Hi Everyone,

This is part 2 of a discussion (see the previous episode for part 1).

We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association).

We discuss the highlights of this two day meeting and some of the takeaway learning points.

Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics!

Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music……

Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below:

Challenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023

Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings

Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art Illustrated Edition. Dr Allan Cyna

Hi Everyone,

We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association).

We discuss the highlights of this two day meeting and some of the takeaway learning points.

Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics!

Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music……

Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below:

Challenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023

Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings

Moran, NF, Bishop, DG, Fawcus, S, Morris, E, Shakur-Still, H, Devall, AJ, et al. Tranexamic acid at cesarean delivery: drug-error deaths. BJOG. 2023; 130(1): 114– 117. https://doi.org/10.1111/1471-0528.17292

You are called to a code blue medical on labour ward – a previously well nulliparous woman has just had a seizure, and now seems confused. Her observations are normal, she is not hypertensive and the CTG appears fine. She is presumed to have had an eclamptic seizure and is given oxygen, magnesium and has some urgent pre-eclampsia bloods and urine sent. The midwife states she has been trying to stay well hydrated with lots of coconut water and has been on oxytocin to augment her labour for a number of hours. Her results are all normal except for a sodium of 111. She suddenly starts to begin seizing again…….

Hi everyone,

This week I am joined by two guests – Siv our current education fellow and Jess who is a senior ICU trainee working in our department to discuss a very important but perhaps somewhat often overlooked condition – peripartum hyponatraemia. As we acknowledge in the podcast hyponatraemia is a huge topic and in order to make this podcast more manageable and practical we have chosen to focus specifically on peripartum hyponatraemia, it’s common causes, recognition & diagnosis, practical management and how to avoid the harms associated with excessively rapid correction.

Thanks Jess!

Guideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period – GAIN Northern Ireland March 2017

Hi Everyone,

In our tertiary women’s hospital here in Perth we use remifentanil PCA in labour approximately 15 times a year – and we are told that in Australian terms this is considered a “heavy user” of this labour analgesic technqiue.

This week I sit down with Mike Jamison an anaesthetic fellow from Belfast spending a year with us here in Perth. When he arrived in WA we quickly learned from him that remifentanil PCA is commonly used for labour analgesia in Northern Ireland with one unit he worked in having prescribed this technique for more than 11,000 women. We sit down to have a deep dive into the use of remifentanil PCA in labour in Northern Ireland. What aspects of their approach have led it to become such a commonly utilised technique? What is their recipe? How do they prescribe it, how do they monitor the women and how is this technique now viewed amongst the obstetric, midwifery and wider Northern Irish community!

If you are attending the upcoming Obstetric Anaesthesia satellite meeting in Sydney in a few weeks – come along to hear Mike talk on this in person!

Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. The Lancet volume 392, p662-672, AUGUST 25, 2018

Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years’ experience. H Murray, P Hodgkinson, D Hughes. Int J Obstet Anesth 2019 Aug;39:29-39

You are referred a patient who needs urgent surgery and the obstetrician tells you she has some obscure medical condition which you have never heard of before. Does her condition have any implications for the safe conduct of anaesthesia? How can you find out in a timely manner what the specific anaesthetic issues are and what anaesthetics have been used safely by others in these patients before?

Hi everyone,

This week I am joined by Siv and Sarah to discuss this tricky situation and to give a free plug for the website orphananesthesia.eu a site started by the German society of anaesthesiology and now contributed to by anaesthesia providers from all over the world to help with these difficult patients.

Correction: In the podcast we referred to Stoelting’s textbook – this text is actually titled “Anesthesia and co-existing disease” – but not dedicated specifically to rare or uncommon disorders. A more relevant text would have been Fleischer et al “Anaesthesia and uncommon diseases”.

https://www.orphananesthesia.eu/en/