Obsgynaecritcare

Hi Everyone, This week we have the audio from another great talk given at our departmental meeting by our colleague Assoc Prof Nolan McDonnell on labour epidural analgesia. This talk was originally given at the Obstetric Anaesthesia special interest group meeting held in Sydney in early May. Nolan discusses many important aspects of the physiology and pharmacology of labour pain, and the history of how the regimen we use in our institution has evolved over the last decade. The second part of the talk centres around the evidence for what is the best epidural analgesia regimen to use in labour and what might the future hold? Thanks again Nolan! For those who would like to view this as a video with the powerpoint slides you can do so here: Video recording - Labour epidural analgesia regimens Nolan Mcdonnell.

(*hypothetical patient) You have a young woman booked for an emergency D&C for a miscarriage. She is in a lot of discomfort from the misoprostol given earlier that day. She hasn't eaten for exactly 6 hours but feels a bit nauseated and has had some oxycodone during the day. According to the 6 hour rule you assume she should be fasted - but she has had opioids because of her pain and you wonder whether she does still have solids in her stomach and will it be safe to just use a supraglottic ariway or should you give her an RSI and used a cuffed endotracheal tube? Is there anyway you can get more information to help you make a decision?? Hi Everyone, This week I am joined by Dr Mark Sharples to discuss gastric ultrasound a fascinating technique which could be the new frontier in perioperative aspiration risk assessment. USEFUL LINKS Gastricultrasound.org NAP4 - airway audit project in the UK  

The emergency pager goes off - code blue medical on the gynaecology surgical ward. As you enter the ward a frantic grim faced nurse waves you into the side room where you discover an elderly woman who is obviously cyanosed, not really conscious and struggling vigorously to breath. She has a hudson mask on her face and there is an obvious tracheostomy tube protruding from her neck. One of the nurses tell you she had a laparotomy for ovarian cancer earlier that day and that she has a long term tracheostomy after having had a throat cancer resected 5 years ago..... Hi Everyone, This week I am joined by another anaesthetist, Dr James Anderson to discuss the perioperative management of tracheostomies. Before seeing the light and jumping the drapes to become an anaesthetist James spent a year working as an ENT registrar and now he has an interest in teaching both perioperative and crisis management of patients with tracheostomies. He helps run tracheostomy crisis management courses at Fiona Stanley Hospital and h

Hi everyone, Join us on the podcast where this week we have part 2 of the discussion with Dr Sonya Ting on tips for management of acute perioperative pain. We explore some advice on how to manage a tricky obstetric patient with post caesarean pain issues. I also failed dismally to entice any responses to last weeks quiz entitled "Anaesthetist or serial killer". In one final last ditch attempt to rescue this quiz from abject failure I have now rebranded it. I have supplied you with a small crossword which can be used to get some hints as to the name of the individual who is pictured - and then I am guessing using the power of  the internet someone should be able to figure out who this is! QUIZ 4 - Anaesthetist or serial killer? Who is this person?

Hi everyone, This week I am joined again by my colleague Dr Sonya Ting - where I attempt to pick her brains for some useful advice in managing difficult perioperative pain issues. Sonya's first episode on the opioid epidemic has already taken first place on the podcast download list as the most popular episode so far! Hypothetical Patient A 50yr old woman is on your list and scheduled to undergo a laparascopic hysterectomy. You see her in the preoperative area: Q - What issues / history should you explore to identify if this patient is at risk of perioperative pain issues? Q - How are you going to explain to her the plan for her perioperative pain management, what are the goals and what strategies fo you use to manage her expectations? Q - What communication strategies can you use, what about non-verbal and verbal communication? Listen to Sonya and I discuss these issues on the podcast - and finally have a crack at the latest instalment of our quiz below: Anaesthetist or Serial Killer? Quiz 4 Is the fo

You are the anaesthetic consultant on call and you are woken (again) at 2am on a Saturday night by your registrar. They tell you they have been asked by the obstetric team to see a pregnant woman who has just arrived in the hospital contracting with ruptured membranes at 30 weeks gestation and is telling everyone "I only have half a heart"! The registrar tells you they have had a look through what they describe as a very large set of patient notes. They tell you it appears that they have been seen by a lot of specialists in the antenatal period but no-one in the overnight team is exactly sure what the plan is for this woman. She is starting to get quite uncomfortable and is asking for some pain relief. The patient herself is not the greatest help - she has told your registrar that she too is confused and that a final decision on how she is going to give birth hasn't been made yet - but everyone seems to be really worried about it! What is the Fontan circulation and what implications does this have for pregna

Hi everyone, This week Graeme and I discuss an interesting case from the past involving a parturient with a partially corrected congenital heart condition who presented a bit of a conundrum in the middle of the night. Before we get into the case discussion however we unpick the prospects for the football (soccer) world cup and admire the Iceland viking clap. Graeme does a bit of a "trump" when he attempts to bluff his way through our world cup conversation by first deploring the antics of the Italian team attempting to fake fouls and he then even picks the Netherlands to win! - and of course neither of these teams are even at the 2018 world cup! Fake news! QUIZ! Finally to beef up this relatively short episode we have another quiz. Who is the person pictured below and why are they famous in the world of obstetrics? Once again no prizes but we will give you a mention on the next episode for a bit of brief internet fame!

(*Hypothetical case) You are a busy gynaecologist working in a large public hospital. You are contacted by a GP on the phone about a young 19yr old patient who you operated on 3 weeks ago - she underwent a laparoscopic ovarian cystectomy. The GP tells you that he referred her to your service for investigation of intermittent pelvic pain about 5 months ago and hasn't seen her since. They inform you that today she turned up for an appointment asking to get a renewal of her Targin 20mg bd which was prescribed by the inpatient team on discharge and which she has been on for the last 3 weeks since leaving hospital. The GP is not very happy! They inform you " she still has the same pelvic pain but now I also have to manage a 19yr old who is hooked on a fairly decent dose of opioids!". They rightly point out that she was a bit depressed before they sent her to you but arguably now she is much worse than she was before and they want to know what you are going to do to help............. What is the "opioid epidemic"

(*Hypothetical case) You are the anaesthetist on for obstetrics and a young woman is rushed from labour ward into your theatre for an emergency caesarean for fetal distress. Your registrar is talking with the patient and so you help with the team time out discussion. The obstetrician leading this asks "can you please give 2g of Cefazolin?". No worries - you grab the 20ml syringe and give the antibiotics over the next 30seconds whilst you help slide the patient onto the table and you instruct your registrar to start topping up her epidural. Your registrar says "no worries" but then looks confused and turns to ask you "where is my syringe?" With a sudden sickening feeling building in your stomach you look down at the now empty 20ml syringe in your hand. You slowly roll it over to reveal a previously hidden sticker....................... "bupivacaine 0.5%" Do you ever use local anaesthetics? This sort of local anaesthetic misadventure is one of those life threatening scenarios which make most anaesthetists br

(*Hypothetical Case) A 26 yr old woman with a suspected ruptured ectopic pregnancy is rushed to theatre in haemorrhagic shock. The patient has a history of IVDU with a naltrexone implant. The team in the emergency department have been unable to get vascular access. She has a heart rate of 150/min and a BP of 75/45. She is now very distressed and unco-operative from both the abdominal pain but also the repeated painful attempts at vascular access with large needles by lots of different healthcare staff! Join Graeme and I as we discuss the various different options for gaining vascular access to allow resuscitation, but also induction of anaesthesia so definitive surgery can occur. We discuss the following various options: USS guided peripheral IV access Intraosseous drills External Jugular peripheral IV cannulation Internal Jugular peripheral IV cannulation  -  "The Rapid IJ" Large bore central cannulation (eg MAC line, swan sheath, haemodialysis catheters) - usually Internal jugular (IJ) and sub

You are in a peripheral hospital without onsite laboratory support after hours and you are involved in the care of a young parturient with uterine atony who has now bled over 2litres. Although you have called in someone to do some laboratory testing - you know that these results will be at least 45-90minutes away. How likely is it that this woman has become  coagulopathic? What approach should you take in this setting? Should you use empiric coagulation supportive therapy? FFP? Fibrinogen? TXA? Hi everyone, This week we have the audio of a great talk Nolan wrote for the obstetric intensive care symposium held in Adelaide earlier this year, and which he then kindly presented to our department in April. Pregnancy is a procoagulant state and during haemorrhage obstetric coagulopathy is actually relatively rare. The underlying mechanisms are different to trauma and other patient groups and we should use this knowledge to help us in our use of blood product therapy especially when rapid coagulation testing (eg

This week Graeme and I take on a big topic! (excuse the pun), You are the anaesthetic consultant on call and you are woken by your registrar at 2am who asks you to come and give them a hand with a difficult patient. They have been asked to come down to labour ward to place an epidural in a supermorbidly obese patient who has arrived and appears to be in established labour. She weighs about 190kg, and has a BMI of over 60. The team have been unable to get intravenous access and they want your help with this too. They are also having trouble measuring her blood pressure accurately because of the shape of her upper arms and she is now getting quite distressed with her pain making it difficult for them to examine her obstetrically and monitor her foetus........ There are many difficult aspects to managing the supermorbidly obese patients. In this podcast Graeme and I discuss some practical tips / points on how to navigate the difficulties which they can present. Super morbid obesity is defined as a BMI >50. W

Hi Everyone, Congratulations & kudos Jeremy Hickey who correctly identified that this blood gas was a sample from a unit of stored allogeneic blood, sorry we don't have any actual prize except for getting a mention on the podcast and the glory of seeing your name in print on the website! (If we have any more quizzes we may have to look into this.) Ryan Juniper also deserves a mention for his post on the facebook page which was also very close. What is the storage lesion of blood? What is 2,3 DPG? What happens to red cell deformability? Join Graeme and I for a 15minute discussion around the changes that occur in allogeneic blood when it is stored and why this may affect both it's function and the undesirable effects this may have on our patients. We also briefly discuss and try to make a case for why salvaging and re-infusing a patients own fresh blood may be a much better option if you can achieve this during surgery - however we will leave a detailed discussion on cell salvage for another episode. Last w

Hi everyone, Join Graeme and I this week where we discuss podcasts for medical education (& recreation). Find out who Alexander Hamilton was and what our favourite medical podcasts are and our personal take on this topic. Want to get into some medical podcasts? Get yourself a good set of earphones, go onto your iphone and into the purple podcast icon (sorry Samsung and Android users Graeme and I can't help you there): Here are some of our favourite podcasts (in no particular order): EMCRIT - Critical care and emergency medicine from NY City ACCRAC - Anesthesia Critical Care Reviews and Commentary - From John Hopkins in the US COG - conversations in Obstetrics and Gynaecology - From Queensland BBC History - No Medicine here but Graeme loves it. The Curbsiders - Internal Medicine topics in depth from the US EDECMO - Cutting edge use of ECMO for cardiac arrest and critical care Intensive Care Network - From The Alfred Hospital in Melbourne - gold! Obsgynaecritcare - subscribe and give these guys a g

Hi everyone, This week on the podcast I have a fascinating interview with Dr Wynand Breytenbach a GP anaesthetist and obstetrician working in Narrogin WA. Join us on the podcast - we have a great conversation where Wynand recounts for us a case he had as a junior doctor working for the South African govt when he was stationed in Namibia on the border with Angola many years ago........ Thanks for listening! Regards Roger

Hi Everyone, After last weeks fascinating case discussion, Nolan and I continue with our discussion on amniotic fluid embolism. In this discussion we drill down into some of the current theories and understanding of the pathophysiology, prevalence, risk factors and AMOSS, the Australasian Maternities Outcomes Surveillance System, which has focussed on AFE in Australasia. The exact biological mechanism of AFE is still not fully understood as this is a rare unpredictable condition with no reproducible animal model which makes it exceedingly difficult to study. The knowledge we currently have has been gleaned from descriptions of case reports / case series and the pathophysiology that was observed. Current theories favour the condition to be an immune mediated reaction triggered by maternal exposure to fetal amniotic fluid and that the term "embolism" may be misleading. Listen to our podcast above for some more nuanced discussion on this topic. If anyone has any comments, questions or personal experiences the

Hi Everyone, This week we have a friend and colleague on the podcast, Assoc Prof Nolan McDonnell where he discusses a challenging case of amniotic fluid embolism which he was personally involved with earlier in his career. Join us and listen to the case where Nolan describes what it was like on a personal level - the uncertainty at first as to what is happening when there is a maternal collapse - and then the clinical utility of transoesophageal echocardiography and inhaled nitric oxide and how they helped in the management of this critically unwell woman. This is a unpredictable and challenging clinical condition which anyone involved in the care of obstetric woman in the peripartum period may be unfortunate enough to encounter. Stay tuned for next weeks podcast where Nolan and I do more of a "deep dive" into the epidemiology, pathophysiology and history of this fascinating condition. Reference McDonnell NJ, Chan BO, Frengley RW. Rapid reversal of critical haemodynamic compromise with nitric oxde in a pa

(*Hypothetical Case) You are an obstetrician (or anaesthetist) and you work in a peripheral hospital in a metropolitan city. You are not on call but despite this you get woken by a phone call at 2am one night. It is a junior obstetric registrar who is very keen for you to come and give them some help. They tell you the on call obstetric consultant is already busy in theatre with an urgent caesarean for fetal distress and isn't currently available. They are on the labour ward with a women who has just had vaginal delivery of twins following a relatively long labour augmented with oxytocin. She now has an atonic uterus and despite oxytocin / ergometrine has bled about 2 litres - she has just reminded everyone that she is a jehovah's witness and reiterates that she will not accept blood under any circumstances. Unfortunately she never had any formal antenatal discussion about blood products - this is the first time she has mentioned it! The registrar sounds very scared and they want your advice about what to do

Hi everyone, Thanks for joining us again, this week I am joined by my colleague Prof Yee Leung, Head of Gynaecological Oncology in Western Australia, to discuss the obstetric and surgical aspects of managing the patient with an abnormally invasive placenta (accreta / increta / percreta). Please join us, listen to our conversation on the podcast and let us know if you have any comments or questions. Definitions: Accreta = the chorionic villi are in contact with the myometrium (78%) Increta =  the chorionic villi invade the myometrium. (17%) Percreta = the chorionic villi penetrate the uterine serosa. (5%) Risk factors: Previous caesarean delivery: The authors of one study found that in the presence of a placenta previa, the risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries, respectively. Placenta previa (without previous uterine surgery): 1–5% risk of placenta accreta. Any condition resulting in myometrial t

(*Fictitious case) You are called to the postnatal ward by the midwife to review a woman who unfortunately had an accidental dural puncture the day before during her labour. When you see her today she has a classic postural headache - and has been unable to mobilise for more than 10-15 min and has basically confined to bed in a dark room. You take a detailed history and perform a neurological exam and are relatively confident that it is unlikely that she has any other serious pathology and that the headache is secondary to the CSF leak. You explain to her the natural history of the condition, discuss epidural blood patch, or conservative management. The patient tells you she is not very keen on the idea of anyone putting another big needle in her back - "isn't there anything else we can try?"   This week on the podcast we are joined again by Gareth Ansell to discuss the role of sphenopalatine ganglion block (SPGB) in the management of postdural puncture headache (PDPH). SPGB is useful in reducing post dur