OB case

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This case brings up a lot of good points. Thanks for the much needed clinical case presentation Noy.
I am here as devils advocate as all of us on this thread have some solid points. Love the mental masturbation of this case.

I will ask however:

What is at the very bottom of the difficult AW algorithm?
Once you are at CICO scenario... what is the NEXT step to save your patient's life? How will you accomplish this?
It's a difficult line to cross, but when you are there you need to mobilize quickly or be left with a corpse.
Definitely good to have thought about these cases b4 they land in your lap.

Again. I have intubated impending AW loss with a surgeon and scalpel with a flash of iodine prep ready to get a definitive AW once I induce.
Luckily, I've have not had to have a surgeon cut due to failed intubation.

The exception is the Trauma bay. That is a place where you may skip out on the DL/AFOI/whatever and go right for a surgical AW.

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What is at the very bottom of the difficult AW algorithm?

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Fetus is dying. How are you gonna topicalize a septic, edematous, hysterical pt to perform an AFOI? This sounds like the answer but in reality, you are not going to do this. The edema alone won't topicalize enough to do it in a calm pt.
AFOI is not going to work, so don't waste your time or the fetus' last moment trying.

Ok fine, obviously there is no good choice here. If your choices are;

A.) GETA; OB pt equals RSI by the book, but here I'd argue her risk of lost airway is greater than her aspiration risk, therefore consider your spontaneous breathing GA induction of choice. Ketamine likely better than volatile from a vasodilation standpoint as well as likely being faster. And again, I'll vouch for asleep FOB techniques, including thru LMA if you need to.

B.) Awake trach, assuming someone skilled enough to do this was in house. Maybe in the real world these are 2 min procedures but I've yet to see one that I would call fast.

C.) Avoid the airway and spinal her. Assuming no time for the ol' epidural dose it slow plan you're going to be dealing with hypotension and may need to do A anyway.

So, if you're taking away all reasonable plans, and now it's emergent..... I'll be the crazy devils advocate and say maybe, just maybe throwing a spinal in her isn't the worst of the 3 options. I think we all could keep her perfused with volume lines and a cvl/PICC. But then the issue becomes what do you do when she needs tubed mid-case...... Though, at that point presumably baby is safe and sound.

I think oral board examiners tell you to do option C while I still lean towards A and trust my ability to get the airway or cut the neck if absolutely necessary.

Obviously, addressing the airway before the baby stops behaving is the best plan.

Good case.
 
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B.) Awake trach, assuming someone skilled enough to do this was in house. Maybe in the real world these are 2 min procedures but I've yet to see one that I would call fast.

If you are doing big cases in the "real world"... my first piece of advice is to know your surgeons and what THEY are capable of.

2 min. crics/trachs--->>> ohhh yeah... all the time. They don't even call anesthesia for the ICU trachs.
 
Sure, I can see a 2 min cric/trach in emergent get in or pt is dead scenarios, and yes, in the ICU as well. But I'm not sure either of those are the same as an anxious fully awake swollen obese pregnant woman with a fetus crashing inside of her.
 
Sure, I can see a 2 min cric/trach in emergent get in or pt is dead scenarios, and yes, in the ICU as well. But I'm not sure either of those are the same as an anxious fully awake swollen obese pregnant woman with a fetus crashing inside of her.

And i think that is a point of the thread. It would probably work for some, maybe not for others. What can YOU do to make it thorugh this case? Decisions.

I would think that a cric under near local toxicity at around 25 degrees with some talking might be a lot more palatable than 45 min. of attempted FOI with no definitive AW. I mean... def. give it a try but don't get hung up on it if it's near impossible.
 
So the case went like this.
The pt stared to improve and was weened off the pressors. Labor continued and apparently she delivered vaginally today in the ICU without any anesthesia involvement.

Sorry so boring!
 
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So the case went like this.
The pt stared to improve and was weened off the pressors. Labor continued and apparently she delivered vaginally today in the ICU without any anesthesia involvement.

Sorry so boring!

So OB backed off. Made your life easier.

There is nothing "boring" about an ICU patient delivering vaginaly in the ICU!

How is the little guy/gal?

No, just a lame one. ;)

Dang... broseph... thanks for making me feel like a pile of rusted 'ol wheels.... What if I said Browski?
 
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With the concerns of septic shock and you're still more worried about the airway and you're willing to go down path C of the spinal, would you consider just doubt a spinal catheter? Titrate up slowly and go from there?

I remember I ended up placing a spinal catheter on my oral boards. Still passed.

Ok fine, obviously there is no good choice here. If your choices are;

A.) GETA; OB pt equals RSI by the book, but here I'd argue her risk of lost airway is greater than her aspiration risk, therefore consider your spontaneous breathing GA induction of choice. Ketamine likely better than volatile from a vasodilation standpoint as well as likely being faster. And again, I'll vouch for asleep FOB techniques, including thru LMA if you need to.

B.) Awake trach, assuming someone skilled enough to do this was in house. Maybe in the real world these are 2 min procedures but I've yet to see one that I would call fast.

C.) Avoid the airway and spinal her. Assuming no time for the ol' epidural dose it slow plan you're going to be dealing with hypotension and may need to do A anyway.

So, if you're taking away all reasonable plans, and now it's emergent..... I'll be the crazy devils advocate and say maybe, just maybe throwing a spinal in her isn't the worst of the 3 options. I think we all could keep her perfused with volume lines and a cvl/PICC. But then the issue becomes what do you do when she needs tubed mid-case...... Though, at that point presumably baby is safe and sound.

I think oral board examiners tell you to do option C while I still lean towards A and trust my ability to get the airway or cut the neck if absolutely necessary.

Obviously, addressing the airway before the baby stops behaving is the best plan.

Good case.
 
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how did this case get to be an airway of doom?


sure she's pregnant and fat ... so are almost all the GA sections i've ever done
 
how did this case get to be an airway of doom?


sure she's pregnant and fat ... so are almost all the GA sections i've ever done

I'm guessing from the gazillion liters of unnecessary crystalloid that most ICUs give to septic patients.
 
how did this case get to be an airway of doom?

Because it's an oral board scenario. :)

You forgot that she has a primary vaginal herpes outbreak and neurosyphilis!!!!!!!!

Well, that's small potatoes compared to her being a Jehovah's witness with a starting Hb of 6, the MH susceptibility, her unstable c-spine, acute methamphetamine intoxication, an 8 cm aortic root aneurysm, acute renal failure. Also, she's looking a touch jaundiced.
 
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True. The PICC has a 16 & 20X2 g ports. It's an F'n central line.
And it was placed when she got to our facility, not from the outside facility that sent her home.
The problem with these lines is their length which significantly increases their resistance and slows down the flow, but it is a central line very good for pressors, and I would Just get a good peripheral IV for volume.
 
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This was my thinking during all of this as well. Nifedipine is out for obvious reasons but I wasn't sure about terbutaline. I didn't want her HR any higher so I was thinking it wasn't a good idea at the time. But now with things stabilizing somewhat it might be reasonable.
This was my discussion with the OB who obviously was making these decisions, not me.
OB tells me that terbutaline never works but it's probably worth a try.

How many times have you seen a pt come into your OR with a HR 140 after terbutaline. I saw it a lot when FP managed laboring pts and midwives of course. Not so much with OB.

Everything that will decrease her contractions will also drop her BP. Terbutaline is a Beta2-agonist, i.e. vasodilator.

AFAIK, contractions can rarely be stopped long-term, especially if the patient is contracting q2 min.
Epinephrine would stop the contractions and increase the BP, worth considering in this case
 
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The real question is did the doula approve all of these treatment options and integrate them into the patient's birth plan?
 
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If that is the case wouldn't norepinephrine do the same?

I wouldn't think to the same extent that epi should. Norepi is primarily an alpha agonist while epi is a beta agonist, specifically beta-2. Stimulation of which causes uterine relaxation.
 
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I wouldn't think to the same extent that epi should. Norepi is primarily an alpha agonist while epi is a beta agonist, specifically beta-2. Stimulation of which causes uterine relaxation.

At what doses? I know epi's B2 effect dominates at low doses. but ive never used it for its B2 effect before. At doses we give in the OR alpha dominates B2
 
At what doses? I know epi's B2 effect dominates at low doses. but ive never used it for its B2 effect before. At doses we give in the OR alpha dominates B2
This patient needs both alpha as a pressor and beta as a tocolytic so epinephrine is a reasonable option and in that case, you titrate your dose per hemodynamics and take whatever beta effect you can get.
 
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I can see some of you haven't treated a lot of urosepsis; I have seen quite a few unfortunately and a central line is essential in this patient at some point. Could you do it after the baby is out? Yes. But, the hypotension will only get worse with the GA and the use of additional pressors is all but guaranteed.

Since I know that an arterial line and central line can be placed in under 4 minutes (total) with the use of u/s in experienced hands that's the route I would go here just like I've done countless times in my career.

The a-line and central are easy calls. As far as I'm concerned, the risk of not placing it far outweighs the risk of placing it.
 
Would you mask induce any patient (who has a working IV) who's considered to be at higher risk for aspiration?

Agree 100%.

Plus mask induction works great for kids. Not so great for adults (takes a lot longer to accomplish conditions that would allow you to DL a patient... with a full stomach). Works really well if you want to keep the uterus nice and boggy though.
 
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(takes a lot longer to accomplish conditions that would allow you to DL a patient... with a full stomach)

She'll deliver before you get this BMI 47 pregnant pt deep enough to DL with a mask induction.
 
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I am not sure why people think that mask induction allows maintaining spontaneous ventilation and prevents losing the airway in a morbidly obese patient!
 
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I am not sure why people think that mask induction allows maintaining spontaneous ventilation and prevents losing the airway in a morbidly obese patient!

This is a good point, especially for junior residents etc. I agree entirely. I would still argue that there is a difference between soft tissue obstruction and central apnea however. But the point remains that causing any reduction in muscle tone may lead to loss of a patent airway in any patient prone to obstruct.
 
This is a good point, especially for junior residents etc. I agree entirely. I would still argue that there is a difference between soft tissue obstruction and central apnea however. But the point remains that causing any reduction in muscle tone may lead to loss of a patent airway in any patient prone to obstruct.
Seriously. Has anyone not been able to ventilate a patient purely due to obesity (obviously airway tumors are a different beast). Oral airway appropriate size mask and and two strong hands should be fine and you will be able to mask ventilate this patient if the need arises
 
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Fetus is dying. How are you gonna topicalize a septic, edematous, hysterical pt to perform an AFOI? This sounds like the answer but in reality, you are not going to do this. The edema alone won't topicalize enough to do it in a calm pt.
AFOI is not going to work, so don't waste your time or the fetus' last moment trying.

I won't do it then.

I'll just put her to sleep and see what happens. If the airway is lost and it all goes to hell I will just call the ENT to save the day.o_O
 
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