Anaesthesia Archives - obsgynaecritcare: Recent Episodes
Roger Browning - Anaesthetist
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.
ReferencesMaternal anesthesia for EXIT procedure: A systematic review of literature.
The management of congenital upper airway anomalies and the ex-utero intrapartum treatment (EXIT) procedure
The post 135 The EXIT procedure with Lloyd Green appeared first on obsgynaecritcare.
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 / LinksA 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.
The post 134 Journal Club – a discussion of the 2023 Gerard Ostheimer lecture with Matt Rucklidge appeared first on obsgynaecritcare.
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.
REFERENCESNAP7 – Royal College of Anaesthetists
The post 133 NAP7 a discussion and review with Jacob appeared first on obsgynaecritcare.
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.
Useful ReferencesThe post 132 The soiled airway with Nathan Blakely appeared first on obsgynaecritcare.
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…
ReferencesDumitrascu 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
The post 126 Anaesthetic management of the pregnant woman with Achondroplasia with Declan appeared first on obsgynaecritcare.
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.
The post 124 Journal club with Declan appeared first on obsgynaecritcare.
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 AUSTRALIANThe post 123 Obstetric anaesthesia and the abnormal spine with Graeme appeared first on obsgynaecritcare.
Hi everyone,
Welcome to part 3 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!
The post 121 PBM Case discussion with Anastazia and Nolan part 3 blood is not an option. appeared first on obsgynaecritcare.
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 […]
The post 117 Toxicity of neuraxial tranexamic acid with Graeme appeared first on obsgynaecritcare.
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 […]
The post 116 Epidural local anaesthetics and another TXA article with Siv appeared first on obsgynaecritcare.
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 […]
The post 115 Congenital bleeding disorders in pregnancy with Dr Anastazia Keegan appeared first on obsgynaecritcare.
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:
ReferencesChallenges 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
The post 114 Highlights from the OA SIG Meeting Sydney part 2 appeared first on obsgynaecritcare.
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:
ReferencesChallenges 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
The post 113 Highlights from the OA SIG Meeting Sydney part 1 appeared first on obsgynaecritcare.
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”.
Referenceshttps://www.orphananesthesia.eu/en/
The post 110 Rare diseases and OrphanAnesthesia with Siv and Sarah. appeared first on obsgynaecritcare.
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!
ReferencesPreventing 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.
The post 109 Radial arterial line strategies to prevent failure with Graeme & Siv appeared first on obsgynaecritcare.
(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.
“Lloyd’s Recipe”1. Check the patient’s oxygen sats whilst supine – pre induction (use to plan target sats intra & post) 2. Individualise FiO2 for pre-oxygenation and not necessarily 100% for most (usually 80%) 3. Have the APL valve at around 5cm H20 when preoxygenating 4. Head-up / ramped (to maintain FRC) 5. Recruitment manoeuvre after intubation and before pneumoperitoneum – use a machine technique not hand recruitment. 6. Start with a PEEP 5-8cm H20, individualise during the case – may need higher whilst head down and pneumoperitoneum. 7. Small Tidal Volumes (TV) 5-8ml/kg of ideal body weight – (obese patients don’t get bigger TV’s) 8. Keep FiO2 < 0.4 9. I:E ratio 1:1 10. If disconnection – repeat recruitment maneouvre 11. At emergence / extubation – sitting upright, don’t disconnect to suction ETT, recruit again if laparoscopic procedure or obese. 12. Routinely use NM monitoring – ensure TOFR >0.95 13. Don’t use 100% O2, Aim FiO2 < 0.8 14. If breathing on manual ventilation setting have APL valve at 5-10 to maintain PEEP 15. Squeeze bag as extubating 16. Immediately post extubation place face mask with APL still at 5-10 17. Be cautious / avoid excessive opioids that will suppress respiratory drive in PACU
ReferencesA 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)
The post 108 Postoperative pulmonary complications and protective lung ventilation strategies with Lloyd Green appeared first on obsgynaecritcare.
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!:
ReferencesThe 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
The post 107 TIVA for GA caesarean with Parita & Sneha appeared first on obsgynaecritcare.
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!
LINKSReducing 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
The post 106 NRFIT and wrong route errors – a discussion with Graeme. appeared first on obsgynaecritcare.
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 […]
The post 105 Nitrous oxide for labour analgesia with Graeme appeared first on obsgynaecritcare.
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 […]
The post 104 Oral midodrine a discussion with Rheily appeared first on obsgynaecritcare.
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 […]
The post 103 How to perform an epidural blood patch. appeared first on obsgynaecritcare.
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 […]
The post 102 Neuraxial anaesthesia for caesarean delivery part two appeared first on obsgynaecritcare.
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 […]
The post 101 Neuraxial anaesthesia for Caesarean section Part one appeared first on obsgynaecritcare.
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 […]
The post 100 Learning from real haemorrhage case discussions appeared first on obsgynaecritcare.
Welcome to this podcast, the eighth in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss all things relating to obstetric haemorrhage, a much feared […]
The post 097 Obstetric haemorrhage appeared first on obsgynaecritcare.
Welcome to this podcast, the seventh in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to […]
The post 096 General anaesthesia for Caesarean section part 2 appeared first on obsgynaecritcare.
Welcome to this podcast, the sixth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to […]
The post 095 General anaesthesia for C Section part 1 appeared first on obsgynaecritcare.
Welcome to this podcast, the fifth in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss eclampsia, pre-eclampsia, hypertensive disorders and the specific issues relating […]
The post 094 Eclampsia, pre-eclampsia and hypertensive disorders in pregnancy appeared first on obsgynaecritcare.
Welcome to this podcast, the four in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss the approach to a woman with a suspected or […]
The post 093 Post dural puncture headaches appeared first on obsgynaecritcare.