Arterial lines – let’s face it who doesn’t love them? When you have a truly sick patient these humble and often underrated devices bring so much to the table, precise control of the haemodynamics, assessment of gas exchange, blood sampling to assess coagulation, anaemia and many other parameters. There is nothing more frustrating however when these lines don’t go in easily, malfunction or stop working altogether…..

Hi everyone,

This week I sit down with Graeme and Siv to dissect & discuss a great review article. The authors do a great job performing a deep dive into almost every imaginable aspect of their use, including insertion techniques, ultrasound, angle of insertion, length, size, site, construction, securement, and more. Join us and no matter what your level of experience I am sure you will learn something new – I know I certainly did!

Preventing radial arterial catheter failure in critical care – Factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med 2022 Aug;41(4):101096.

*Unfortunately this is an article in a journal owned by Elsevier (in my humble opinion a company not very supportive of open access) and is behind a pay-wall. You can access this through the ANZCA library or your own institutions library in some cases.

(Hypothetical case)

You are called to the PACU to review a patient, who despite face mask oxygen has saturations of only 88%. She is a woman in her 50s who has just undergone a 3 hour laparoscopic hysterectomy for endometrial cancer. She has a BMI of 48, has been a smoker for 30 years, and had a chest infection 3 weeks ago. When she walked into the hospital earlier this morning she was breathing relatively normally. She had a long period of time when we she was steeply head down, there was a pneumoperitoneum of gas pushing on her lung bases and we were positively ventilating her with the anaesthetist choosing what gas mixture, pressures and ventilation modes they used. What has happened during this operation and anaesthetic that now she has serious respiratory dysfunction here only a few hours later in PACU?

Are there any strategies that we could have employed intraoperatively to try and minimise or avoid postoperative respiratory problems like this?

Join Lloyd and I as we discuss this thorny issue which is not uncommon in gynaecological patients having laparoscopic and open abdominal surgery.

Part 1: We discuss post pulmonary dysfunction and consensus statements on the topic.

Part 2: We talk about practical intraoperative & postoperative strategies you might consider to try and protect the lungs and prevent any problems.

A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications BJA 2018 May 120(5)

Postoperative pulmonary complications BJA: British Journal of Anaesthesia, Volume 118, Issue 3, March 2017,

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis BMJ 2020; 368

Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations BJA 2019 Dec;123(6)

Hi everyone,

This week three of us sit down to discuss a great review article (and topic) – the use of TIVA (total intravenous anaesthesia) for GA caesarean surgery.

For many the classic technique for a GA caesarean has been thio / sux tube then volatile & nitrous oxide. In recent years many aspects of this have started to change with propofol probably more commonly used as the i.v. induction agent and now in many cases rocuronium is used in preference to suxamethonium. Now with the much increased use of TIVA across anaesthesia practice there is a renewed interest in it’s role for women having caesarean surgery and GA for management of postpartum haemorrhage.

Join us as we discuss this article. What do we mean by TIVA? What are the potential benefits? (uterine tone, recovery, PONV) and are there risks? (awareness, fetal depression, over sedation).

It is fair to say there has not been a lot of high quality research done on this topic and there are more questions than definitive answers, but this article does well to summarise the issues and what we do know.

Informal Twitter Poll result from Parita!:

The role of total intravenous anaesthesia for caesarean delivery. Y. Metodiev, D.N. Lucas IJOA April 08, 2022

Comments on above article – M.Paech IJOA June 28, 2022

Hi Everyone,

You receive a phone call at 2am from a junior colleague who tells you that they are managing a code blue caesarean section and in the confusion of urgently administering a number of different medications they have just accidentally injected 10ml of cephazolin into the epidural catheter instead of the intravenous tubing. They are understandably upset and worried. (* This is a hypothetical scenario).

What are wrong route errors? How common are they? How do they happen?

Article from 2012 – “The US Pharmacopeia, the largest information source of tube misconnection related errors, has received 1600 reports of epidural to central or peripheral intravenous misconnections since 1999.”

What is NRFIT and how will this help improve patient safety? When is it coming? – It is already here and will probably coming to your health service soon. Many hospitals around the world including all of Japan have already changed over and a few sites in Australia / NZ have also now introduced NRFIT.

Join Graeme and I as we discuss the issue of wrong route errors, and what you need to know about NRFIT, as well of course a few bad Xmas jokes!

Reducing Risk of Epidural-Intravenous Misconnections – APSF Newsletter Winter 2012

Challenges when introducing NRFit™ at a tertiary hospital in Japan International Journal of Obstetric Anesthesia, 2022-02-01, Volume 49, Article 103244 . This article is behind Elseviers firewall but you should be able to access it through the ANZCA library or your own hospitals if you are lucky enough to have these available.

NRFIT Pajunk

Stay connected GEDSA NRFIT website

Hi everyone,

This week Graeme and I sit down for the first time in nearly a year and do a bit of a deep dive on the use of nitrous oxide as an analgesic in labour. We drop a few dad jokes, discuss the history of inhaled analgesics, nitrous oxide use around the world, the evidence, the environmental concerns and other interesting anecdotes.

Do you have nitrous oxide on labour ward in your part of the world? Send us a comment and let us know!

Enjoy

ANZCA Blue Book 2021 (Australasian Anaesthesia) – go to page 183

Developments in labour analgesia and their use in Australia 2015

Safety and Utility of Nitrous Oxide for Labor Analgesia APSF Journal June 2020

Your 76 yr old patient is now two days post her laparotomy for ovarian cancer. She looks well, is starting to eat and keen to get up to the shower as well as have all the “annoying lines and tubes removed from my arms!”.

Unfortunately she is still on 3ml/hr of a metaraminol infusion and everytime the nurse tries to wean it off her BP drops to 70/45….. Is there anything you can do?

Hi everyone,

This week Rheily and I discuss the pharmacology of oral midodrine a alpha adrenergic agonist useful as an oral systemic vasoconstrictor. Join us as we discuss the ins and outs of using oral midodrine – please leave us a comment if you have some experience or tips to share!

USEFUL LINKS

Australasian Anaesthesia 2019 (Blue Book) Article – go to page 101

Hi everyone,

This week Sneha leads a discussion with both Matt and myself where we take a deep dive into how to actually perform an epidural blood patch. Even though you can’t really classify this as an uncommon procedure, as individuals we probably don’t do very many and it is hard for most of us to become experienced and “expert” (whatever that is defined as).

We discuss the evidence, the effectiveness, the practical considerations and some of the common problems / difficulties which may be encountered.

Thanks Sneha (for organising and leading this episode) and of course you too Matt!

Epidural blood patch: A narrative review – Anaesthesia Critical Care & Pain Medicine October 2022

Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch International Journal of Obstetric Anesthesia 2019

Welcome to this podcast, the tenth in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to neuraxial anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out).

Thanks Shilpa, Matt & Roger!

The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area.

1 – Epidural analgesia in labour part 1

2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting

3 – Accidental dural puncture and intrathecal catheters

4 – Post-dural puncture headaches and management

5 – Pre-eclampsia, eclampsia and hypertensive disorders

6 – General anaesthesia for Caesarean Delivery part 1

7 – General anaesthesia for Caesarean Delivery part 2

8 – Obstetric Haemorrhage

9 – Neuraxial anaesthesia for Caesarean Delivery part 1

10 – Neuraxial anaesthesia for Caesarean Delivery part 2

Welcome to this podcast, the ninth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to neuraxial anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out).

Thanks Shilpa, Matt & Roger!

The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area.

1 – Epidural analgesia in labour part 1

2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting

3 – Accidental dural puncture and intrathecal catheters

4 – Post-dural puncture headaches and management

5 – Pre-eclampsia, eclampsia and hypertensive disorders

6 – General anaesthesia for Caesarean Delivery part 1

7 – General anaesthesia for Caesarean Delivery part 2

8 – Obstetric Haemorrhage

9 – Neuraxial anaesthesia for Caesarean Delivery part 1

10 – Neuraxial anaesthesia for Caesarean Delivery part 2

Hi everyone,

Join us this week as we briefly celebrate the 100th episode – almost exactly 5 years after the first episodes aired. Then we sit down to discuss some real haemorrhage cases – a follow up on our promise from the earlier episode 97 where we discuss the basics of managing obstetric haemorrhage.

Thanks Graeme, Shilpa and Matt!

097 Obstetric haemorrhage

MBRRACE-UK – Maternal mortality and morbidity reports UK