Let's talk OB

[gasresident1]

Happy Thanksgiving! So OB has been great as a new attending. Let's have some fun. I'll start with some of my joys this year, feel free to chime in how you would approach these and your fun stories.

1) Fresh off the street in street clothes. Baby de-celling. A BIIIIIIG momma. No veins visible to the eyes, no time to roll in an ultrasound from the OR, no vein finder. Gotta go, gotta cut. Only thing available is sevo, nitrous, mask, and IM ketamine?

2) Again, mom coming in off the street, got an IV. But oh shoot, Mallampati IV --> can't see jack with the VL. LMA and go???

3) 10cm dilated and screaming her butt off in pain. Cursing everyone out. Will throw punches until an epidural is in but can't stay still for jack. Spinal? How much heavy bupi? Opoids?

4) Mom has moderate AS and MS. Refusing general.

5) Mom in sickle cell crisis. Baby de-satting. Urgent section needed. Epidural in luckily.

6) Your partner screwed you over with a patchy epidural, said nothing. You come on shift and stat c - section. Bolus and level not up to par. Sit her up and do a spinal?

7) Your partner did a CSE two hours ago with spinal dose. Now going back for urgent section and the epidural is patchy. Do you keep going with lido, or stop and try a new spinal. What dose of spinal? Am I gonna get a high spinal?

8) Seizure after delivery. Already on magnesium as she wasss pre eclamptic, now eclamptic. Oxygen sat is dipping a bit.

9) Your partner wet tapped. Decided it was a great idea to place an intra thecal catheter rather than just going to another space. Now running at 3cc of 0.125 bupi. She can't move her legs. What is the dose anyway for a running intra thecal catheter. I never learned that in residency. They would kick me out of residency for something as stupid as this. Oh great, the baby is of course de celling. We might have to go back for section, what do I dose this thing? Is she gonna get a high spinal. She's huge, and a Malampati III-IV. I can't deal with this now.

10) Doing a CSE for a routine CS. Awww, breathe of fresh air. She's thin too, not the BMI 40 I'm used to. Everything goes perfectly but the Arrow catheter does NOT thread. Turn 180, recheck, turn 180. Thread and nope. Pull out a little and re engage. Still not threading. No time to check another level before the spinal becomes a sacral. Lie her down and hope for the best in a patient that has had two sections and an abdominal surgery previously. Normally, I just do spinals for these anyways? Surgeon kinda slow tho, she needs to retire.

11) Mom is pre E, on mag. She uses an inhaler "once in a while", maybe "3 times in the last 3 years". The uterus is boggy as crap and if we don't fix this she will keep bleeding.

I'll start with these. Learning curve has been great so far. Especially neuraxial / regional. Being an attending is a lot different than passing a little gas and getting it out.

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[Crabbygas]

Ignoring the fact that it's kinda lame that I am surfing SDN on thanksgiving..... I'll have a go at a couple of these.

1: Call for help. Sevo, LMA, cut, find vein, intubate through LMA if it makes you feel better.

2: Again, call for help if available, LMA, intubate through LMA if it's not working great. Get more practice with fiberoptic on elective cases.

3: Spinal 1cc of .25 bupiv and 25mcg fentanyl. If you aren't sure she delivers soon and don't want to come back add whatever your usual spinal dose of duramorph.

 

[coffeebythelake]

I don't do OB much anymore but my thoughts here..

1. She needs and IV or an IO. Otherwise she is getting minimal anything except nitrous and maybe some IM versed ketamine. What she needs is GA. No time to muck around w neuraxial. If this is truly an emergent c section that cannot wait it is potentially a largely local procedure.

2. SGA then fiber through it to secure the airway. You've already induced and burned that bridge. The aspiration risk is already present. I would prefer the surgeon wait to cut until airway is secured but if it is truly emergent do both simultaneously

3. Spinal if pt can hold on. Otherwise some opuoids and nitrous. Neuraxial anesthesia here is an elective procedure. No sense poking yourself because the patient is thrashing about while you are holding a needle.

4. Epidural dosed up slowly (or small dose spinal then dosing up the epidural) with fluid coloading. If worried place an art line.

5. Dose epidural, give fluids, give plenty of supplemental oxygen. Keep warm. Review labs that she isnt super anemic and consider txfn if she is. Basic HbSS management stuff. Nothing special here.

6. This woman needs a GA. Spinal dosing after just trying large volumes through patchy epidural is asking for high spinal.

7. Try chloroprocaine or lidocaine via epidural and trouble shoot it briefly to see if a more even surgical anesthetic achievable. Otherwise GA

8. Benzo. Prepare to intubate.

9. What is her level?

10. Why cse for routine c section. Do straight Spinal. What does this even mean -- "No time to check another level before the spinal becomes a sacral."?!

11. Double pit, other utertonics. Didnt read that part about preX so yeah avoid methergine. . TXA. Send for T+C and get good access. Is this truly due to poor uterine tone? Bakri, etc. This pt might need IR or more aggressive measures.

 

[Bryan O’Blivion]

1. IO. That’s really what it’s there for. Use the big one. In the best bone.
2. Intubate through SGA.
3. IV fentanyl to hold still, using nitronox. At 10 cm? Yes, it will be ok. Or refuse, if you aren’t comfortable.
4. Epidural. Bring it up slowly. Use a steady increase in neo infusion to balance pressures.
5. Keep really warm and oxygenated on NRB, flood with warm fluids.
6. Nope. GETA under controlled circumstances.
7. Pull epidural. Place spinal. Full dose. Unlikely to get high spinal. Fairly likely with question 6.
8. Intubate. Propofol gtt to unit. Agree with BZD, keppra.
9. I am that guy. IT is fine for labor and cesarean. 0.75-1.25 **cc**heavy bupi, depending on level. There’s a catheter, you can add more.
10. Try 20 gauge nylon filament catheter. If no go, spinal it is. Tell surgeon no CSE, make like a sewing machine and get it on.
11. Recognizing that methergine can be dangerous in pre E post op, may consider with icu monitoring. Not everyone with “asthma” Will bronchospasm with hemabate. If you choose to punch that ticket, *consider* pre treat with albuterol, have dilute epi drawn up. But before you make either of these two devil’s bargains, make sure your pit bolus/infusion is adequate. Bolus with extreme predjudice, but keep in mind the BP will tank, so use pressor accordingly.

 

[dabears505]

What are the legal implications if you induce with gas with no iv in a pregnant patient? The mother aspirates. Do the lawyers cut you slack that the baby was going to die?

 

[TheLoneWolf]

What are the legal implications if you induce with gas with no iv in a pregnant patient? The mother aspirates. Do the lawyers cut you slack that the baby was going to die?

I think the legal term is "cut you from sternum to scrotum".

Ie they will disembowel you

 

[coffeebythelake]

What are the legal implications if you induce with gas with no iv in a pregnant patient? The mother aspirates. Do the lawyers cut you slack that the baby was going to die?

I am not a lawyer... but I am quite certain you will be sued to high heaven because it is a major deviation from acceptable practices. You can argue extenuating circumstances given the baby's condition but medicolegally your primary responsibility is the mother and this is malpractice..

 

[HemeOncHopeful19]

Do the lawyers cut you slack...?

I'm not a lawyer, anesthesiologist or a big pregnant lady but I can answer this one: No.

 

[pgg]

1) Fresh off the street in street clothes. Baby de-celling. A BIIIIIIG momma. No veins visible to the eyes, no time to roll in an ultrasound from the OR, no vein finder. Gotta go, gotta cut. Only thing available is sevo, nitrous, mask, and IM ketamine?

You're out of your mind

Straight up nuts

Koo-koo for Cocoa Puffs

Don't do that

2) Again, mom coming in off the street, got an IV. But oh shoot, Mallampati IV --> can't see jack with the VL. LMA and go???

Yes, LMA is next in the difficult airway algorithm.

Later, when all is stable, reflect a little on why you induced a dodgy-looking airway. First duty is to the woman.

3) 10cm dilated and screaming her butt off in pain. Cursing everyone out. Will throw punches until an epidural is in but can't stay still for jack. Spinal? How much heavy bupi? Opoids?

1) She can scream. Epidurals are elective.

2) "Miss, if you're going to abuse and assault the staff here, I'm not going to put in an epidural. You need to calm down."

3) Consider a dose of IV fentanyl to take the edge off while you work on the epidural. Tell her you'll put an epidural in when she's able to hold still. Go sit at the nurse's station and play with your phone until she chills out.

4) Mom has moderate AS and MS. Refusing general.

Why does she need general anesthesia? An epidural is not contraindicated.

Does "MS" mean mitral stenosis (an epidural is not contraindicated), or multiple sclerosis (an epidural is not contraindicated)?

5) Mom in sickle cell crisis. Baby de-satting. Urgent section needed. Epidural in luckily.

What's the problem? Dose the epidural and deliver the baby.

6) Your partner screwed you over with a patchy epidural, said nothing. You come on shift and stat c - section. Bolus and level not up to par. Sit her up and do a spinal?

ALL patchy/lousy epidurals, repeat ALL, get pulled and a spinal is placed. If it's truly stat, and the airway is reassuring, put her to sleep. If the airway isn't reassuring, come up with a safe plan to put her to sleep or do a spinal.

I personally think the concern for high spinal, if you do a spinal after a failed epidural augment, is BS academic dogma, so I wouldn't be opposed to doing a spinal, if indicated.

7) Your partner did a CSE two hours ago with spinal dose. Now going back for urgent section and the epidural is patchy. Do you keep going with lido, or stop and try a new spinal. What dose of spinal? Am I gonna get a high spinal?

All patchy/lousy epidurals get pulled and a spinal is placed. Usual dose. No, you won't.

8) Seizure after delivery. Already on magnesium as she wasss pre eclamptic, now eclamptic. Oxygen sat is dipping a bit.

What's the question? If she needs an airway, give her one.

9) Your partner wet tapped. Decided it was a great idea to place an intra thecal catheter rather than just going to another space. Now running at 3cc of 0.125 bupi. She can't move her legs. What is the dose anyway for a running intra thecal catheter. I never learned that in residency. They would kick me out of residency for something as stupid as this. Oh great, the baby is of course de celling. We might have to go back for section, what do I dose this thing? Is she gonna get a high spinal. She's huge, and a Malampati III-IV. I can't deal with this now.

In general, dose the intrathecal catheter with 1/10th whatever you usually use in the epidural space.

3 cc/hr is a bit high; I'm not surprised she can't feel her legs. I start intrathecal catheters at 1 cc/hr - though in full disclosure, I've only done <10 of these in my career (if I count my own wet taps and those from residents I was supervising).

No, you won't get a high spinal - unless you do silly things. The great thing about the catheter being there is that you can give incremental doses. I'd probably start with 1 cc of the 0.5% isobaric or 0.75% hyperbaric bupivacaine. Be aware that the volume of the catheter itself is a non-trivial fraction of 1 cc, so typically I'll pull a cc or two of CSF off, give your drug, then flush the CSF back in.

10) Doing a CSE for a routine CS. Awww, breathe of fresh air. She's thin too, not the BMI 40 I'm used to. Everything goes perfectly but the Arrow catheter does NOT thread. Turn 180, recheck, turn 180. Thread and nope. Pull out a little and re engage. Still not threading. No time to check another level before the spinal becomes a sacral. Lie her down and hope for the best in a patient that has had two sections and an abdominal surgery previously. Normally, I just do spinals for these anyways? Surgeon kinda slow tho, she needs to retire.

Why a CSE for a routine, non-obese c-section? The surgeon is that slow + expected adhesions from previous surgery? Bummer.

What did you dose the spinal with?

Tell the surgeon that she's got 2 hours to finish before the block wears off. If she thinks it'll be close, tell her to call in an assistant.

11) Mom is pre E, on mag. She uses an inhaler "once in a while", maybe "3 times in the last 3 years". The uterus is boggy as crap and if we don't fix this she will keep bleeding.

Oxytocin, misoprostol. Load TXA for good measure. I'd personally give this person Hemabate (carboprost) as a 3rd agent if she was still bleeding.

 

[ERRES2288]

I am not a lawyer... but I am quite certain you will be sued to high heaven because it is a major deviation from acceptable practices. You can argue extenuating circumstances given the baby's condition but medicolegally your primary responsibility is the mother and this is malpractice..

Yes. IO or US IV. Not going to sleep until get access.

 

[Southpaw]

great OB anesthesia experience @gasresident1. Bravo.

 

[coffeebythelake]

Local infiltration for c section. Not a great option but it is an option in dire circumstances. Perhaps supplemented with some IM versed.

Cesarean section under local anesthesia: A step forward or backward?

www.ncbi.nlm.nih.gov

 

[woopedazz]

1,2,3...10,11: spinal.

😜

 

[cchoukal]

Local infiltration for c section. Not a great option but it is an option in dire circumstances. Perhaps supplemented with some IM versed.

Cesarean section under local anesthesia: A step forward or backward?

www.ncbi.nlm.nih.gov

And if she bleeds without an IV?

 

[Lecithin5]

Happy Thanksgiving! So OB has been great as a new attending. Let's have some fun. I'll start with some of my joys this year, feel free to chime in how you would approach these and your fun stories.

1) Fresh off the street in street clothes. Baby de-celling. A BIIIIIIG momma. No veins visible to the eyes, no time to roll in an ultrasound from the OR, no vein finder. Gotta go, gotta cut. Only thing available is sevo, nitrous, mask, and IM ketamine?

Nitrous and local; work on getting IV. No way in heck am I giving Im ketamine or sevo etc. Sorry. Even worse than not having an iv is giving drugs where you emergently need to reverse or counteract their side effects. Don’t want to lose an airway.

2) Again, mom coming in off the street, got an IV. But oh shoot, Mallampati IV --> can't see jack with the VL. LMA and go???

LMA; hope she doesn’t aspirate; work on intubating afterwards (either via LMA, fiberoptic, etc)

3) 10cm dilated and screaming her butt off in pain. Cursing everyone out. Will throw punches until an epidural is in but can't stay still for jack. Spinal? How much heavy bupi? Opoids?

Pt not getting neuraxial if she cant stay still. Will need GA if c section. I have on occasion given some versed (making the OB and pt know that I was doing this; risks/benefits- they can get nicu involved if they want)

4) Mom has moderate AS and MS. Refusing general.

Epidural, plus/minus aline

5) Mom in sickle cell crisis. Baby de-satting. Urgent section needed. Epidural in luckily.

6) Your partner screwed you over with a patchy epidural, said nothing. You come on shift and stat c - section. Bolus and level not up to par. Sit her up and do a spinal?

If there is time, replace epidural. Otherwise likely GA. I alwayd hesitant to place a spinal after an epidural, especially if I had been bolusing it…

7) Your partner did a CSE two hours ago with spinal dose. Now going back for urgent section and the epidural is patchy. Do you keep going with lido, or stop and try a new spinal. What dose of spinal? Am I gonna get a high spinal?

Replace epidural if time. Not a fan of spinal after epidural, although some of my partners do it with obviously a reduced dose (but how much?! That gets tricky, which is why I generally don’t)

8) Seizure after delivery. Already on magnesium as she wasss pre eclamptic, now eclamptic. Oxygen sat is dipping a bit.

GA intubate if worried about airway. Treat seizure. Otherwise facemask. Icu if needed. Not sure what the question is.

9) Your partner wet tapped. Decided it was a great idea to place an intra thecal catheter rather than just going to another space. Now running at 3cc of 0.125 bupi. She can't move her legs. What is the dose anyway for a running intra thecal catheter. I never learned that in residency. They would kick me out of residency for something as stupid as this. Oh great, the baby is of course de celling. We might have to go back for section, what do I dose this thing? Is she gonna get a high spinal. She's huge, and a Malampati III-IV. I can't deal with this now.

Start at 1cc/hr of 0.125, and uptitrate from there for labor analgesia. If need a csec, push about 1cc of 0.75 bupi, and push more as needed. Can always give more.

10) Doing a CSE for a routine CS. Awww, breathe of fresh air. She's thin too, not the BMI 40 I'm used to. Everything goes perfectly but the Arrow catheter does NOT thread. Turn 180, recheck, turn 180. Thread and nope. Pull out a little and re engage. Still not threading. No time to check another level before the spinal becomes a sacral. Lie her down and hope for the best in a patient that has had two sections and an abdominal surgery previously. Normally, I just do spinals for these anyways? Surgeon kinda slow tho, she needs to retire.

Yes, abort threading attempts and lay her down and hope for best. Unfortunately, has happened to me more than once in the past. Usually works out OK. Convert later on to GA if needed

11) Mom is pre E, on mag. She uses an inhaler "once in a while", maybe "3 times in the last 3 years". The uterus is boggy as crap and if we don't fix this she will keep bleeding.

Pitocin, cytotec. Avoid methergine. Hemabate probably okay

I'll start with these. Learning curve has been great so far. Especially neuraxial / regional. Being an attending is a lot different than passing a little gas and getting it out.

I do the most OB out of our group of 70 docs in one of the busiest centers in country (doc-only practice). The situations you have described are excellent thought-provoking scenarios. Most of the time it goes well until it doesn’t. GA is in fact an OK option- I remember being scared to do this during residency, because the attendings always made it seem as though every parturient would be a difficult intubation. Some certainly are, but usually it goes fine.

 

[Lecithin5]

And if she bleeds without an IV?

I’m with you- reality is that this lady will need an IV at some point (sooner rather than later obviously). While OB is working under local, you (along with partners if you have any) work like mad trying to get one. Even a central line. Whatever you have to do. I have come across a situation like this, and it was very stressful, but we got it done. Surgeon infiltrated, got baby out pretty quickly, and me and my partner were able to get an IV under ultrasound within 5-10 minutes of incision (waiting for ultrasound arrival, etc). Bmi of patient was about 60. It was an awful experience for everybody, but mom and baby did alright in the end.

 

[coffeebythelake]

And if she bleeds without an IV?

I dont think you understand my meaning. You would still look for access, but this would allow them to proceed with the extrication of a crashing baby in the mean while.

 

[deleted875186]

1. This is crazy. No anesthesia of any kind without an IV, that is unless I am called to a code. Potential for harm to mother is ridiculously high. Certainly higher than the theoretical risk to the fetus from the FHT.


I’m only a few years out, but I will say there is no textbook answer for a lot of these, just best judgement. Risk of GA is exaggerated in my opinion, it is a good option for many of the “epidural not working” or “could get a high spinal” questions. Honestly, if a partner left me a intrathecal catheter, and something comes up, I’d give them a call on their cell and ask them how they would dose it if unsure. Otherwise do the reasonable thing and dose it incrementally if in an urgent situation.

 

[Ezekiel2517]

6) Your partner screwed you over with a patchy epidural, said nothing. You come on shift and stat c - section. Bolus and level not up to par. Sit her up and do a spinal?

7) Your partner did a CSE two hours ago with spinal dose. Now going back for urgent section and the epidural is patchy. Do you keep going with lido, or stop and try a new spinal. What dose of spinal? Am I gonna get a high spinal?

I think the key in both of these situations is determining if the epidural is questionable prior to bolusing it. If you don't feel confident in the epidural, place a spinal in the OR with a slightly reduced bupi dose. An epidural that has just been bolused is a different story tho imo. You essentially have a significant volume of local just sitting there next to the dura. If placing a spinal in this scenario, I'd probably reduce the bupi to around 1 cc

 

[DrOwnage]

I think the key in both of these situations is determining if the epidural is questionable prior to bolusing it. If you don't feel confident in the epidural, place a spinal in the OR with a slightly reduced bupi dose. An epidural that has just been bolused is a different story tho imo. You essentially have a significant volume of local just sitting there next to the dura. If placing a spinal in this scenario, I'd probably reduce the bupi to around 1 cc

Placing a spinal in a just fully dosed epidural is no cake walk either if it’s anything but an easy spinal. I had a time where I did a spinal over an epidural bolus with questionable “pop” but the fluid that came back was most likely epidural bupi. Spinal didn’t work. If there’s time I replace the epidural in the OR instead. If it’s urgent/emergent just do general will make your life less stressful.

 

[zizzer]

1) Fresh off the street in street clothes. Baby de-celling. A BIIIIIIG momma. No veins visible to the eyes, no time to roll in an ultrasound from the OR, no vein finder. Gotta go, gotta cut. Only thing available is sevo, nitrous, mask, and IM ketamine?

Agree with no anesthesia until IV/IO. I'd use my Butterfly ultrasound, but I realize that's not an option for everyone. If your OB floor doesn't have an ultrasound, that's a problem that needs to be fixed later.

2) Again, mom coming in off the street, got an IV. But oh shoot, Mallampati IV --> can't see jack with the VL. LMA and go???

LMA and surgical airway if necessary... but how can't you see anything with VL? I've never had that happen except in maybe a oropharynx cancer case or something maybe. Try a quick repositioning, taking out the pillow, making sure there's no big bun of hair under her head.

3) 10cm dilated and screaming her butt off in pain. Cursing everyone out. Will throw punches until an epidural is in but can't stay still for jack. Spinal? How much heavy bupi? Opoids?

Tell her calm down or no procedure.

4) Mom has moderate AS and MS. Refusing general.

Tell her that general anesthesia is always the backup plan even if starting with neuraxial. Assuming nonurgent, I would probably consider dosing an epidural incrementally with 2% lidocaine with 1:100K epinephrine.

5) Mom in sickle cell crisis. Baby de-satting. Urgent section needed. Epidural in luckily.

Dose epidural for surgical coverage and transfuse PRBCs.

6) Your partner screwed you over with a patchy epidural, said nothing. You come on shift and stat c - section. Bolus and level not up to par. Sit her up and do a spinal?

Probably just general anesthesia at this point for me. High/total spinal after failed epidural may or may not be real, but I don't know for sure and many people I respect claim that it is, so why not do general anesthesia? It's not that big of a deal as long as you know what you're doing.

7) Your partner did a CSE two hours ago with spinal dose. Now going back for urgent section and the epidural is patchy. Do you keep going with lido, or stop and try a new spinal. What dose of spinal? Am I gonna get a high spinal?

If you haven't given a big volume of loading for a surgical epidural, perhaps try spinal as long as airway is reassuring. If airway isn't reassuring, consider: dosing epidural hoping you'll get lucky and if coverage isn't good, do general anesthesia to manage the airway in a controlled way with preoxygenation rather than reactively after total spinal possibility.

8) Seizure after delivery. Already on magnesium as she wasss pre eclamptic, now eclamptic. Oxygen sat is dipping a bit.

IV benzodiazapines and airway management as necessary.

9) Your partner wet tapped. Decided it was a great idea to place an intra thecal catheter rather than just going to another space. Now running at 3cc of 0.125 bupi. She can't move her legs. What is the dose anyway for a running intra thecal catheter. I never learned that in residency. They would kick me out of residency for something as stupid as this. Oh great, the baby is of course de celling. We might have to go back for section, what do I dose this thing? Is she gonna get a high spinal. She's huge, and a Malampati III-IV. I can't deal with this now.

Placing an intrathecal catheter isn't "stupid" just because you don't know how to handle it. However, placing an intrathecal catheter without a bunch of thorough instructions to everybody involved is irresponsible. Dose with about 1/10 the dose of an epidural or just call your partner and see what she or he recommends. Obviously turn it down currently.

10) Doing a CSE for a routine CS. Awww, breathe of fresh air. She's thin too, not the BMI 40 I'm used to. Everything goes perfectly but the Arrow catheter does NOT thread. Turn 180, recheck, turn 180. Thread and nope. Pull out a little and re engage. Still not threading. No time to check another level before the spinal becomes a sacral. Lie her down and hope for the best in a patient that has had two sections and an abdominal surgery previously. Normally, I just do spinals for these anyways? Surgeon kinda slow tho, she needs to retire.

General anesthesia if surgeon is too slow.

11) Mom is pre E, on mag. She uses an inhaler "once in a while", maybe "3 times in the last 3 years". The uterus is boggy as crap and if we don't fix this she will keep bleeding.

Uterotonics as not contraindicated (misoprostol 800mcg buccal is always handy). TXA. Blood transfusion PRN.

 

[Twiggidy]

1......

Honestly, nowadays, even if they mention to me that the patient is a difficult stick, I don't even head towards the room without the ultrasound. Everything on OB is an end of the world emergency on OB and quite frankly, the end of the world will have to wait until I show up with the ultrasound. Start at the AC and work your way up the arm until you're at the neck. Anytime the OR upgrades their ultrasounds make sure they send whatever isn't being used up to OB so at least "something" is up there.

These situations are tough especially if you're solo in the hospital because more often than not there's nothing ready, but in this case, get some catheter in some vein and get some drugs through it so you can at the very least glidescope this lady.

 

[CD125]

Threads like this make me especially appreciate my OB free practice.

 

[deleted875186]

Reflecting on number 1 more. Really a culture problem with OB. The obstetricians should realize how dangerous this is for mom and everyone should be trying to facilitate getting an iv. “No time for ultrasound” should instead be “OB nurse is setting up ultrasound for you in the OR and getting a CVC kit in case as well”. If someone tried to get me to induce without access in a healthy mom I would probably escalate this to the head if the anesthesia department.

 

[dabears505]

Also the trouble is when there is a c9mplication, it is entirely on you. Some of the OBs know that and just want to avoid trouble with bad fetal outcome and pit the aspiration/ Airway outcome on you.

The thing with OB is to try and keep the drama to a minimum. It's tough when you are young and coming out, but complications do happen and sometimes when you are trying to be the hero you can get yourself in trouble.

 

[marr65]

A big momma w/o an IV means she is getting a stick in the neck with an U/S. Most central line kits have a needle with a long 20G catheter, just use that instead of threading the big central line catheter. Big momma 99% of the time will have a nice juicy IJ, shouldn’t take you more than 2-3 mins from start to finish.

OB usually has their U/s on the labor deck. Call for that if you don’t have your own.

 

[Arch Guillotti]

A big momma w/o an IV means she is getting a stick in the neck with an U/S. Most central line kits have a needle with a long 20G catheter, just use that instead of threading the big central line catheter. Big momma 99% of the time will have a nice juicy IJ, shouldn’t take you more than 2-3 mins from start to finish.

OB usually has their U/s on the labor deck. Call for that if you don’t have your own.

It takes 1 minute to put one of these in. I prefer a longer single lumen catheter though. The problem is getting the crap in there in an emergency especially when OB is away from the main OR.

 

[gcc322]

. “No time for ultrasound” should instead be “OB nurse is setting up ultrasound for you in the OR and getting a CVC kit in case as well”

You know they will have the transvaginal probe on the ultrasound, right?

 

[abolt18]

You know they will have the transvaginal probe on the ultrasound, right?

Usually a curvilinear probe.

 

[nimbus]

It takes 1 minute to put one of these in. I prefer a longer single lumen catheter though. The problem is getting the crap in there in an emergency especially when OB is away from the main OR.

Seems like a good idea to stock all that stuff on L&D.

 

[vector2]

Happy Thanksgiving! So OB has been great as a new attending. Let's have some fun. I'll start with some of my joys this year, feel free to chime in how you would approach these and your fun stories.

1) Fresh off the street in street clothes. Baby de-celling. A BIIIIIIG momma. No veins visible to the eyes, no time to roll in an ultrasound from the OR, no vein finder. Gotta go, gotta cut. Only thing available is sevo, nitrous, mask, and IM ketamine? .

I'm concerned you do the kind of high risk OB described in the OP but you don't have a dedicated ultrasound for the OB floor. The places I've worked at with that kind of OB made the move to try to get their own like 10 years ago. In this day and age it's a must, even if the cost needs to be subsidized by the hospital or the OB dept.

 

[ranvier]

I was thinking of picking up some OB shifts next year. Now reconsidering. Good discussion.

 

[zizzer]

Since there's good discussion here, I will add another case to get some thoughts.

Add on RCS for G2P1 at 35 weeks with obesity (BMI 69), severe OSA, PreE c/b pulmonary edema on 6 LPM FM. She can't lie flat and had a rapid response called for respiratory distress using accessory muscles. Some form of URI but negative COVID-19 test, obligate mouth breather. On furosemide. CXR looks like ****. TTE shows good biventricular function still ruling out cardiomyopathy of pregnancy.

When I go talk to her, I can hear the fluid gurgling from her lungs when she's talking. Airway exam is reassuring for intubation. When I discuss neuraxial and general anesthesia approaches, she becomes hysterical because the 1st year attending MFM OB told her it would be done with a spinal like her 1st C/S.

What is your approach? If general anesthesia, what's your plan for intubation and extubation?

 

[vector2]

Since there's good discussion here, I will add another case to get some thoughts.

Add on RCS for G2P1 at 35 weeks with obesity (BMI 69), severe OSA, PreE c/b pulmonary edema on 6 LPM FM. She can't lie flat and had a rapid response called for respiratory distress using accessory muscles. Some form of URI but negative COVID-19 test, obligate mouth breather. On furosemide. CXR looks like ****. TTE shows good biventricular function still ruling out cardiomyopathy of pregnancy.

When I go talk to her, I can hear the fluid gurgling from her lungs when she's talking. Airway exam is reassuring for intubation. When I discuss neuraxial and general anesthesia approaches, she becomes hysterical because the 1st year attending MFM OB told her it would be done with a spinal like her 1st C/S.

What is your approach? If general anesthesia, what's your plan for intubation and extubation?

No pre-procedure diuretics, no pre-procedure bipap, intubate, don't place any lines, soft extubate, don't do a tap block, dump in the PACU and turf to hospitalist, emergently re-intubate in the middle of the night

 

[woopedazz]

I'll add one:
26 weeker, APH, footling beach, you and midwife are transferring her to theatre from the emergency department when power goes out. You're in an elevator, stuck between floors. No IV, no equipment, no warm blankets, etc. She's pushing and bleeding.

 

[abolt18]

Since there's good discussion here, I will add another case to get some thoughts.

Add on RCS for G2P1 at 35 weeks with obesity (BMI 69), severe OSA, PreE c/b pulmonary edema on 6 LPM FM. She can't lie flat and had a rapid response called for respiratory distress using accessory muscles. Some form of URI but negative COVID-19 test, obligate mouth breather. On furosemide. CXR looks like ****. TTE shows good biventricular function still ruling out cardiomyopathy of pregnancy.

When I go talk to her, I can hear the fluid gurgling from her lungs when she's talking. Airway exam is reassuring for intubation. When I discuss neuraxial and general anesthesia approaches, she becomes hysterical because the 1st year attending MFM OB told her it would be done with a spinal like her 1st C/S.

What is your approach? If general anesthesia, what's your plan for intubation and extubation?

GA. Diurese. Leave intubated.

 

[abolt18]

I'll add one:
26 weeker, APH, footling beach, you and midwife are transferring her to theatre from the emergency department when power goes out. You're in an elevator, stuck between floors. No IV, no equipment, no warm blankets, etc. She's pushing and bleeding.

Please tell me you're joking.

 

[woopedazz]

Please tell me you're joking.

Nope. I was frozen trying to work out what I could actually do. Very bad experience. Power was out for less than 10mins mind you.

 

[sevo00]

When I go talk to her, I can hear the fluid gurgling from her lungs when she's talking.

Lol. Never heard of this before, hearing pleural effusions without a stethoscope.

 

[abolt18]

Lol. Never heard of this before, hearing pleural effusions without a stethoscope.

Pulm edema.

 

[deleted875186]

Since there's good discussion here, I will add another case to get some thoughts.

Add on RCS for G2P1 at 35 weeks with obesity (BMI 69), severe OSA, PreE c/b pulmonary edema on 6 LPM FM. She can't lie flat and had a rapid response called for respiratory distress using accessory muscles. Some form of URI but negative COVID-19 test, obligate mouth breather. On furosemide. CXR looks like ****. TTE shows good biventricular function still ruling out cardiomyopathy of pregnancy.

When I go talk to her, I can hear the fluid gurgling from her lungs when she's talking. Airway exam is reassuring for intubation. When I discuss neuraxial and general anesthesia approaches, she becomes hysterical because the 1st year attending MFM OB told her it would be done with a spinal like her 1st C/S.

What is your approach? If general anesthesia, what's your plan for intubation and extubation?

Laying flat without SOB is pretty much a requirement for sedation or neuraxial, or sleeping at night ….

Needs to be in the ICU, needs GA, followed by more ICU.

 

[Lecithin5]

GA. Diurese. Leave intubated.

Agree. This might be one I might give the cticu a heads up about for possible ecmo (intra or postop), if your facility has the capability. This case sounds very similar to one I have done where we ended up placing the patient on ecmo.

 

[coffeebythelake]

When I go talk to her, I can hear the fluid gurgling from her lungs when she's talking. Airway exam is reassuring for intubation. When I discuss neuraxial and general anesthesia approaches, she becomes hysterical because the 1st year attending MFM OB told her it would be done with a spinal like her 1st C/S.

What is your approach? If general anesthesia, what's your plan for intubation and extubation?

That OB needs a slap upside their head

 

[zizzer]

I prepare the patient for likely general anesthesia but that I'll talk things over with the obstetrician. I go back to the OR where the obstetrician is waiting and acting completely shocked that I'm insisting on general anesthesia, going back and forth with me several times. After patiently and calmly telling her the same thing over and over she finally accepts that I'm not doing a spinal.

Glidescope RSI and case go uneventfully. Nearing the end of the case, I am planning to attempt extubation and do TAP blocks, give sugammadex and what I considered a modest dose of fentanyl to avoid a wild emergence and NPPE in the large, previously hysterical patient. After extubation in back up position, the patient's spontaneous breathing efforts diminish and SpO2 dips into the low 80s. I assist ventilation while having the nurse roll over the Glidescope, prepare an ETT, draw up and give 0.4mg of naloxone, which helps but only a little. At this point patient is breathing spontaneously but dependent on chin lift and jaw thrust with SpO2 in low 90s on oxygen as prior to induction but barely responsive to external stimulus, presumably in hypercarbic respiratory failure.

Being uncomfortable transporting the short distance to recovery like this but wishing to avoid reintubation, I had RT come to the OR, starting BPAP at 16/9, monitoring for a few minutes before transport. I waited in PACU while catching up on the charting for about 25 minutes until she spontaneously started talking. MV on the BPAP was reassuring and she was trending on the right direction anyway so I went to do the next C/S in a patient even larger (242 kg).

Patient recovered well in PACU. In the future, I'll have more respect for obesity hypoventilation syndrome and forego all opioids periextubation, extubating straight to NIPPV or just leave intubated for diuresis.

 

[Beeftenderloin]

I prepare the patient for likely general anesthesia but that I'll talk things over with the obstetrician. I go back to the OR where the obstetrician is waiting and acting completely shocked that I'm insisting on general anesthesia, going back and forth with me several times. After patiently and calmly telling her the same thing over and over she finally accepts that I'm not doing a spinal.

Glidescope RSI and case go uneventfully. Nearing the end of the case, I am planning to attempt extubation and do TAP blocks, give sugammadex and what I considered a modest dose of fentanyl to avoid a wild emergence and NPPE in the large, previously hysterical patient. After extubation in back up position, the patient's spontaneous breathing efforts diminish and SpO2 dips into the low 80s. I assist ventilation while having the nurse roll over the Glidescope, prepare an ETT, draw up and give 0.4mg of naloxone, which helps but only a little. At this point patient is breathing spontaneously but dependent on chin lift and jaw thrust with SpO2 in low 90s on oxygen as prior to induction but barely responsive to external stimulus, presumably in hypercarbic respiratory failure.

Being uncomfortable transporting the short distance to recovery like this but wishing to avoid reintubation, I had RT come to the OR, starting BPAP at 16/9, monitoring for a few minutes before transport. I waited in PACU while catching up on the charting for about 25 minutes until she spontaneously started talking. MV on the BPAP was reassuring and she was trending on the right direction anyway so I went to do the next C/S in a patient even larger (242 kg).

Patient recovered well in PACU. In the future, I'll have more respect for obesity hypoventilation syndrome and forego all opioids periextubation, extubating straight to NIPPV or just leave intubated for diuresis.

If I think a patient would be best served by extubating to BIPAP followed by a prolonged period of close observation, that’s ICU admission criteria all on its own in my book. I actually just did this over the weekend.

Sure, could I pull an RT from their already busy job to come to OR and help me extubate a patient to BIPAP, just so I can take her to PACU (where she may or may not fly) and hand her off to an OB nurse that has zero comfort working with patients on this type of support or sick patients in general, then spend 20 minutes I don’t have observing her, then proceed to take the next patient back to the OR where I’ll be tied up for an hour unable to intervene when the previous patient crashes.

Or, instead of pretending to play ICU in the OB recovery unit, you could just take first patient to ICU, and let them do their job so you can get on with yours.

 

[zizzer]

I see your point, but I should add that this case was done in the main ORs and main PACU with better-qualified RNs I trust for recovery, which has a dedicated RT available usually.

Our hospital usually schedules the BMI >55 C/S's during daytime hours in the main ORs and sends an OB nurse to assist with the usual preop, OR, and PACU nurses.

 

[Beeftenderloin]

I see your point, but I should add that this case was done in the main ORs and main PACU with better-qualified RNs I trust for recovery, which has a dedicated RT available usually.

Our hospital usually schedules the BMI >55 C/S's during daytime hours in the main ORs and sends an OB nurse to assist with the usual preop, OR, and PACU nurses.

Fair enough, but PACU vs OB recovery makes little difference to me here. The patient is critically ill. They belong with the other critically ill patients, and the doctors and nurses who take care of them when they aren't having surgery. The fact that they did well in PACU, although great, was far from guaranteed.

 

[zizzer]

Fair enough, but PACU vs OB recovery makes little difference to me here. The patient is critically ill. They belong with the other critically ill patients, and the doctors and nurses who take care of them when they aren't having surgery. The fact that they did well in PACU, although great, was far from guaranteed.

And if she would have not done well, she would have gone to the ICU.

Perhaps it varies hospital by hospital, but in the large tertiary care hospital I work at and the one I trained at, it's not uncommon to use NIPPV in PACU on occasion to see how patients do with close monitoring until a disposition is decided. As mentioned earlier, I had some charting to catch up on from the aforementioned events, so I stayed with the patient, assuring good SpO2 with a good BPAP seal on the patient's face and MV near 10LPM. Before I left, the patient was on a clearly improving trajectory clinically (less somnolent).

She avoided ICU stay, postoperative intubation, and was monitored safely, so I don't see what the problem is there. I personally feel more comfortable with the patient sitting right beside a good and careful PACU RN I know and trust with clear instructions and an audible continuous SpO2 than in some ICU room with a nurse I don't know on another floor with some unknown physician or possibly midlevel somewhere on a pager.

 

[deleted875186]

And if she would have not done well, she would have gone to the ICU.

Perhaps it varies hospital by hospital, but in the large tertiary care hospital I work at and the one I trained at, it's not uncommon to use NIPPV in PACU on occasion to see how patients do with close monitoring until a disposition is decided. As mentioned earlier, I had some charting to catch up on from the aforementioned events, so I stayed with the patient, assuring good SpO2 with a good BPAP seal on the patient's face and MV near 10LPM. Before I left, the patient was on a clearly improving trajectory clinically (less somnolent).

She avoided ICU stay, postoperative intubation, and was monitored safely, so I don't see what the problem is there. I personally feel more comfortable with the patient sitting right beside a good and careful PACU RN I know and trust with clear instructions and an audible continuous SpO2 than in some ICU room with a nurse I don't know on another floor with some unknown physician or possibly midlevel somewhere on a pager.

I agree, I sometimes prefer patients like this to do HFNC or BIPAP in PACU, anticipating they’ll improve with a little time, then make a big deal with ICU. I find the ICU admission process and transfer process unneccesarily cumbersome.

Caveat is there must be an anesthesiologist free or immediately available to babysit. Wouldn’t fly if I was on call and solo.

 

[vector2]

I agree, I sometimes prefer patients like this to do HFNC or BIPAP in PACU, anticipating they’ll improve with a little time, then make a big deal with ICU. I find the ICU admission process and transfer process unneccesarily cumbersome.

Caveat is there must be an anesthesiologist free or immediately available to babysit. Wouldn’t fly if I was on call and solo.

Sure, some superfat OSA guy or gal has a relatively uncomplicated surgery and needs some NIPPV in the PACU to wake up for a couple hrs? No big deal.

A repeat section in a BMI 69, severe OSA, pre-E, frank pulmonary edema, can hear "gurgling" when she talks, on diuretics, can't lie flat, and who is going to autotranfuse/fluid shift a large volume after delivery....should probably go to the ICU imo.