Hi Everyone,

Thanks to Mason Habel from Northern Health in Victoria, who contacted us a few months ago and suggested this topic to us. Join Graeme and I as we try to tackle this topic in a comprehensible manner. We do jump around a little bit, chasing anecdotes, interesting historical facts and the occasional dodgy dad joke but hopefully we get there in the end!

LINKS

054 – Neurological injuries after childbirth and neuraxial anaesthesia.

053 – Complications after central neuraxial blocks in obstetric anaesthesia a discussion with Graeme

046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge

Hypothetical case:

You are called to a code blue medical on the gynaecology ward. A patient in her late 60s has collapsed in the bathroom. You are told she was admitted earlier that day for investigation of a probable pelvic cancer. She is conscious, has a heart rate 130/min, NIBP 90/45, SPO2 94% on hudson mask, and is mildly SOB with a respiratory rate 30/min.

This patient undergoes investigation and is diagnosed with a large pulmonary embolism.

She deteriorates suddenly with the following vitals: groaning, HR 145/min, NIBP 60/35, SpO2 85%, Respiratory rate 35/min.

What is the physiology and what are the principles behind the resuscitation of a patient with an acute right ventricular emergency like this?

Fluids? Vasopressors? Inotropes? Thrombolysis? Intubation? Pulmonary vasodilators?

Join Graeme and I as we discuss this particularly challenging scenario which can be both hard to diagnose and resuscitate. There are some important and critical differences to other common causes of deterioration, and serious traps to be aware of and avoid.

Whilst educating myself on this topic I realised that I wasn't as up to speed on this as I thought I was! Thanks to the following resources which I have listed below which I strongly recommend:

USEFUL LINKS

EMCrit 272 – Right Heart Failure with Sara Crager

PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?

Hi everyone,

This week I am joined by Matt & Graeme to discuss induction drugs and adjuncts used in general anaesthesia for caesarean delivery, with a few obligatory dad jokes thrown in at the end if you make it that far!

Hypothetical cases we discuss:

1 - Healthy woman rushed to theatre with cord prolapse and fetal compromise

2 - A woman with severe preeclampsia needs urgent caesarean delivery because of fetal compromise. She has a platelet count of 18, and a BP of 210/120.

3 - A woman ruptures her uterus attempting a VBAC and arrives in theatre with a heart rate of 170/min and BP of 60/40

USEFUL LINKS

The future of general anaesthesia in obstetrics BJA Education 2016

Hypothetical patient:

You get called by an anaesthetic registrar to come and help them with a woman in labour ward. They tell you that they have been struggling for a number of hours now to get a woman comfortable. They have placed three epidurals and topped them up aggressively with generous doses of the usual bupivacaine and fentanyl medications but none of them seem to have been effective. The woman told them that she has had similar problems in the past with dental procedures and minor skin procedures when younger - she also states she has Ehlers-Danlos syndrome.

Hi Everyone,

This week I am joined by Fionn - a WA anaesthetic trainee currently working with us here. We discuss the fascinating (but distressing) syndrome of resistance to local anaesthetics.

Is it real? (yes)

How common is it - and what do we know about it?

LINKS

https://www.bbc.com/future/article/20170106-the-people-who-cant-go-numb-at-the-dentists

https://www.hypermobility.org/local-anaesthetic

Resistance to local anesthesia in people with the Ehlers-Danlos Syndromes presenting for dental surgery

You receive a call from an obstetrician: "I have a term patient booked for induction of labour this morning. She had an MRI of her brain 4 years ago after a car accident and was told she has an Arnold-Chiari malformation. She is very keen to have an epidural - can she have one?"

Hi everyone,

This week Graeme is back and we sit down to discuss Arnold - Chiari malformations and having a baby - why all the fuss and controversy?

References

Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study

Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia

https://www.orphananesthesia.eu

Ghaly Chiari malformation decision guide - see article above

You are called to a code blue medical on labour ward. A woman who has been in labour attempting a VBAC has just collapsed whilst pushing during the second stage. She is unresponsive, not breathing and looks "bad".

This week I am joined by my two colleagues, also consultant anaesthetists, Dr Emelyn Lee and Dr Lip Ng. Join us for this interesting conversation where we discuss all things relating to cardiac arrest in pregnancy!

Links

https://resus.org.au/

Hi Everyone,

This week I sit down again with Graeme. We discuss WA's isolation & covid bubble, exchange a few crap jokes and have a go at the thorny topic of shivering under neuraxial anaesthesia.

Big thanks to everyone who helped with the OSCAR trial all those years ago, Yelena for teaching me a new trick to stop shivering and to Dr Tim Pavy for giving me two weeks leave to write up my thesis on shivering!

LINKS

The OSCAR trial - prophylactic ondansetron does not prevent or decrease the severity of shivering under spinal for Caesarean.

Hi Everyone,

This week is our first episode of our journal club to discuss interesting recent relevant research papers. We are hoping to do this on a regular basis interspersed amongst the other regular episodes where we choose a topic and explore it in detail.

In this inaugural episode I am joined by a couple of colleagues who have both been on the podcast before. We have decided to choose articles from IJOA - the International Journal of Obstetric Anaesthesia - a journal devoted to obstetric anaesthesia, critical care and perinatology. Prof Mike Paech is the chief editor, has been on it's editorial board almost since it was first started in the 1990s and Dr Matt Rucklidge has also been a reviewer for the journal for a number of years now.

Mike explains the history of the journal and shares some insights of what it is like being a chief editor, and then we discuss four interesting articles from recent editions.

REFERENCES

International Journal of Obstetric Anaesthesia https://www.obstetanesthesia.com/

1.Rocuronium Versus Suxamethonium for Rapid Sequence Induction of General Anaesthesia for Caesarean Section: Influence on Neonatal Outcomes

2. Lower-limb Neurologic Deficit After Vaginal Delivery: A Prospective Observational Study

Case History (*hypothetical patient)

A 33yr old woman presents to a GP complaining of hair loss, cold intolerance, dizziness, extreme fatigue and weight gain. On further questioning the patient states this is her third attempt to seek help over a number of years. She initially sought help for amenorrhoea after her second delivery and was started on oestrogen / progesterone tablets. The second doctor gave her a diagnosis of postpartum depression after eliciting a history of anxiety, tachycardia and feelings of stress and started her on an antidepressant. However the medication didn't help and she tapered them off and didn't return.

On close questioning she recounts that her first delivery was uncomplicated but the second was an emergency caesarean after failure to progress and fetal distress. The surgery was complicated by blood loss of 4 litres and she remembers being told by staff "that the blood was coming out as fast as it was going in". She spent a number of days in the HDU / ICU and her child was bottle fed because she had difficulty establishing breastfeeding due to the traumatic events.

Join Graeme and I again as we discuss this important but rare complication of pregnancy.

References

Diagnosis and Treatment Challenges of Sheehan's Syndrome

Sheehan's syndrome in modern times: a nationwide retrospective study in Iceland

QUIZ

Which of these is a doctor and which is a serial killer? - and who are they!

Hi Everyone,

This week on the podcast I am joined by Dr Andi Atkinson one of the obstetric and gynaecology trainees here in WA. A few years ago Andi took time off during her training to spend time working in Africa for MSF on two separate occasions and we sat down to record an interview where she explains the processes involved in working with MSF and reflects on some of her experiences during her missions. Andi is still training here in WA but tells me she intends to work again for MSF sometime in the near future. Thanks for sharing your stories Andi!

Links

MSF Australia https://msf.org.au/