Critical care Archives - obsgynaecritcare: Recent Episodes
Roger Browning - Anaesthetist
Hypothetical Case:
You finish injecting the spinal anaesthetic for your patient who has come for an urgent caesarean section. She has pre-eclampsia and her blood pressure just before you started was 180/100.
Just after lying down she starts vomiting and unfortunately the non invasive blood pressure cuff is going up and down but not giving you a number – she is shaking and can’t stop moving around. Is she vomiting because of hypotension, should you give her a bolus of phenylephrine? What if she is actually still hypertensive – you don’t want to push her BP over 200. Wouldn’t it be great if you had a beat to beat continuous display of her BP – maybe you should have placed an arterial line before starting. Are there any other options that might have been helpful???
Hi everyone,
This week I am joined by John to discuss continuous non-invasive blood pressure monitoring. Many of these technologies have actually been around for a number of years now, but despite this don’t seem to be in commonplace usage. There does seem to be a recent renewed interest in re-evaluating these technologies. How do these technologies work? How accurate are they? Have there been any improvements? What are the economics and costs?
Thanks John for all your hard work researching this topic!
Methods1. Arterial Applanation Tonometry 2. Volume Clamp Method 3. Photoplethysmography (PPG): Origins to Modern Applications in Wearable Technology
ReferencesEnhancing Patient Safety with Continuous Blood Pressure Monitoring – APSF (Anesthesia Patient Safety Foundation Newsletter 2026)
The post 152 Continuous non invasive blood pressure monitoring. appeared first on obsgynaecritcare.
Hypothetical Case:
You are called to MFAU to see a woman who has just arrived via RFDS (royal flying doctor service)
She is a 23 y.o indigenous woman from the Kimberley in the far north of WA. She is 33/40 G1P0 complex social history and possible substance use disorders
She has PPROM (pre term premature rupture of membranes) and suspected early chorioamniotis and has been given antibiotics / nifedipine and a few litres of crystalloid fluid during the flight.
The obstetric team have evaluated her – she has small for gestational age baby, and is complaining of dyspnoea.
Her observations are: HR 110, NIBP 124/60, SpO2 91% on room air, T38.1
Her bloods are relatively normal except for an unexpected high BNP.
You do a focussed bedside transthoracic ECHO and unexpectedly see on the PLAX (parasternal long axis view) a classical hockey stick / domed appearance of severe mitral stenosis. She also has Pulmonary B-lines (indicating pulmonary oedema) and a flattened interventricular septum, very large atrium & doppler through the tricuspid valve confirms severe pulmonary hypertension.
The team decides she would be better cared for in a hospital with cardiothoracic services – however she suddenly becomes more breathless – SpO2 86% on oxygen, NIBP 80/40 HR 125, and there is a prolonged foetal bradycardia…………………
Hi Everyone,
This week I am joined by Dr Clinton Ellis, a cardiothoracic anaesthetist based in Sir Charles Gairdner Hospital, and Graeme. We discuss the management of rheumatic heart disease in pregnancy – a challenging condition which unfortunately is still relatively prevalent amongst indigenous women here in Australia.
This was a wide ranging discussion so I have decided to split this into two 40min episodes. Even though we talk for over 80min I feel like we just scratched the surface on this! If you have any questions or comments send them through – I will try and get Clinton to answer them.
Finally a huge shout out and thank you to the Darwin based authors of the ANZCA 2023 Blue Book article on this condition: Namrata Jhummon-Mahadnac, Matthew Mathieson, and Akshay Hungenahally! See the link to their well written narrative review on this topic below:
ReferencesAustralasian Anaesthesia 2023 (aka the Blue Book) – see page 39 “Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End”
Oral vaccine could prevent rheumatic heart disease in NZ
VIDEO: Researchers close to a vaccine for strep-A and rheumatic heart disease
The post 149 Rheumatic heart disease in pregnancy part 2 appeared first on obsgynaecritcare.
Hi everyone,
Sepsis is an important cause of mortality and morbidity in our patients. It is common but can be difficult to diagnose, challenging to manage and sometimes downright scary.
After being inspired by listening to an episode from “The Critical Care Commute Podcast” (with Dr Mervyn Singer a UK intensivist involved in sepsis 3.0), Graeme and I sit down to discuss some of these thought provoking areas of sepsis which are controversial and are still actively being researched.
Thanks again Graeme!
ReferencesThe Critical Care Commute Podcast
The post 146 Current challenges and research directions in sepsis appeared first on obsgynaecritcare.
Hi Everyone,
This week I sat down with Declan to discuss a fascinating therapy which is used in many areas of medicine.
This podcast has a bit of everything, a quiz, a part one viva, dubious animal experimentation, discussions about laxatives, and even some references to cosmology and the Big Bang.
Thanks Declan for another entertaining episode.
The post 143 Magnesium in medicine with Declan appeared first on obsgynaecritcare.
Hi everyone,
This week I am joined again by Dr David Owen an obstetrician here at KEMH. We sit down to discuss uterine inversion – an acute obstetric emergency. Luckily this condition is relatively rare – however because of this there can be challenges in recognising and treating this condition even amongst experienced individuals.
Should you be unlucky enough to encounter this rare condition, now having listened to our discussion you will be better prepared and confident you know what is required!
Thanks again David for your research and preparation for this episode!
ReferencesUterine inversionPararajasingam, S.S. et al.BJA Education, Volume 24, Issue 4, 109 – 112
Unfortunately (as of Feb 2025) this article is not yet open access – but it is very good if you can get it through your hospital or college library..
Uterine Inversion for the layperson – Cleveland Clinic
The post 141 Uterine inversion with Dr David Owen appeared first on obsgynaecritcare.
Hi Everyone,
Welcome to Part Two of our discussion with two of the founding members of the Placenta Accreta Spectrum Team here at KEMH Dr Matt Epee-Bekima and Dr David Owen. This team was conceived in 2017 and began operating in 2018 – and has now cared for over 75 women with PAS – including 24 alone this year (2024). In this episode we continue our initial discussion with a more detailed dive into:
- Surgical management – team members, techniques and approach
- Techniques for catastophic bleeding – manual aortic compression, vascular clamping, interventional radiology
- Postpartum issues
- Controversies (ICU vs HDU, leaving placenta in -situ)
- Thoughts for the future
Thanks Matt & David for sharing the experiences and knowledge learnt by the PAS team over the last 7 years.
Referenceshttps://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Placenta-Accreta.pdf?thn=0
The post 140 The Placenta Accreta Spectrum Team at KEMH Part two. 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 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 ReferencesGupta 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
Hyperkalaemia
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.
The post 131 Hyperkalaemia in Pre Eclampsia a discussion with Natalie Smith appeared first on obsgynaecritcare.
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
ReferencesCoagulopathy 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!
The post 130 Coagulopathy in abruption a discussion with Graeme appeared first on obsgynaecritcare.
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!
ReferencesUterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India
Tocogram characteristics of uterine rupture: a systematic review
The post 128 Uterine rupture a discussion with Dr David Owen appeared first on obsgynaecritcare.
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
ReferencesMaternal Mortality Report Australia
Maternal Mortality World Health Organisation WHO
MBRRACE-UK Maternal mortality reports UK
Signup to receive email notification of each new episode We don’t share email addresses and we don’t send spam
First Name
Last Name
Email address:
Leave this field empty if you're human: The post 127 Maternal mortality reports with Dr Matt Rucklidge appeared first on obsgynaecritcare.
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.
ReferencesGewirtz 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.
The post 125 PRES a discussion with Graeme 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.
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
ReferencesEvaluation 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.
The post 122 Reflections on the THOR THUNDER conference with Graeme and Emelyn 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,
Welcome to part 2 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 120 PBM case discussion with Anastazia and Nolan part 2 postpartum anaemia appeared first on obsgynaecritcare.
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!
ReferencesHow 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.
Understanding Elevated Lactate
The post 118 Challenges of lactate interpretation with Tim and Declan 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.
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!
ReferencesGuideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period – GAIN Northern Ireland March 2017
The post 112 Peripartum hyponatraemia with Jess & Siv 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.
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, 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.
Hi everyone, This is the second episode of two, where I sit down with my anaesthetic colleague Sneha and senior ICU trainee Jess to discuss the important and sometimes scary […]
The post 099 Maternal sepsis with Jess and Sneha Part 2 appeared first on obsgynaecritcare.
Hi everyone, This is the first episode of two, where I sit down with my anaesthetic colleague Sneha and senior ICU trainee Jess to discuss the important and sometimes scary […]
The post 098 Maternal sepsis with Jess and Sneha Part 1 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.
You get called to a code blue medical in the maternofetal assessment unit of your labour ward. A pregnant woman at 35 weeks has presented in severe respiratory distress. Her […]
The post 089 – Acute pulmonary oedema with Graeme appeared first on obsgynaecritcare.
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 […]
The post 068 – Discussion of Sheehan’s syndrome with Graeme appeared first on obsgynaecritcare.
A 28 yr old woman at 36/40 G2P1 presents with a few days history of mild headache, nausea, anorexia, and some upper right abdominal pain. You do some observations and […]
The post 066 – HELLP Syndrome a discussion with Graeme. appeared first on obsgynaecritcare.
Join Matt and I as we discuss some of the issues we have been grappling with in our planning for how to manage obstetric patients suspected of or known to […]
The post 065 – Reflections on COVID and implications in our obstetric unit with Matt Rucklidge. appeared first on obsgynaecritcare.
(*Hypothetical Case) A woman is brought into your emergency dept by her husband at 14 weeks gestation. He tells you that she has been “really sick” for almost two months […]
The post 064 – Can you die from vomiting in pregnancy – hyperemesis gravidarum more than just morning sickness appeared first on obsgynaecritcare.