OB death

[deleted126335]

How did they even get pregnant...

It’s called the prime directive.

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[abolt18]

How did they even get pregnant...

This has been discussed in detail in the past. All I can say is that you're better off not knowing.

 

[deleted162650]

All I can say is that you're better off not knowing.

Maybe he’s into that sorta thing?

 

[GassYous]

Maybe he’s into that sorta thing?

From the sounds of it, it would take me all day to get into that sorta thing

 

[DocVapor]

From the sounds of it, it would take me all day to get into that sorta thing

I have not personally confirmed this, but I am aware of, uhm, instructional videos that can be quite informative in regards to technique.

 

[deleted162650]

I have not personally confirmed this

Riiiiiiiiiiight.

 

[GassYous]

I have not personally confirmed this, but I am aware of, uhm, instructional videos that can be quite informative in regards to technique.

bbw?

 

[IlDestriero]

I haven't done it but have wished I had a few times. Twice had to intubate big fat patients because of subjective dyspnea laying flat when the spinal got up to T6 or T4. They completely freaked out and were going to come off the OR table.

Midazolam not ETT.

 

[deleted162650]

bbw?

I had him pegged as more of a bbc guy.

 

[GassYous]

I had him pegged as more of a bbc guy.

Can't beat that accent

 

[deleted162650]

Can't beat that accent

Not that bbc

 

[DocVapor]

Not that bbc

I don't know what all these acronyms mean but noone can match my Schwartz.

 

[Mman]

Midazolam not ETT.

would've need 10+ mg of midaz which isn't exactly the best for the baby

 

[jwk]

It’s called the prime directive.

Splash technique

 

[abolt18]

From the sounds of it, it would take me all day to get into that sorta thing

I just remember reading comments about 3rd party involvement and 2x4s.

 

[GassYous]

I had him pegged as more of a bbc guy.

Sounds like pegging is your kind of thing

 

[pjl]

would've need 10+ mg of midaz which isn't exactly the best for the baby

A couple of mine legitimately desaturated when supine.

Also, after learning the how, take it from your elder: you can’t unhear/unsee the techniques.

 

[Twiggidy]

I'm sure this topic is discussed elsewhere on the forum but since this is an OB thread I thought I'd bring it up.

Platelet count.

Do you have a "too low" cutoff? I know there's literature/recommendations which more or less say "We're not saying you 'shouldn't' do an epidural/spinal if low but we're also not saying there's a cutoff.....which in my book is near useless.

I understand why cutoffs are problematic but at this point I want a sense of what the community is doing.

 

[deleted162650]

Do you have a "too low" cutoff?

Yes, but it increases by 10k every hour after 2300 until 0700 at which point it resets.

 

[DocVapor]

I'm sure this topic is discussed elsewhere on the forum but since this is an OB thread I thought I'd bring it up.

Platelet count.

Do you have a "too low" cutoff? I know there's literature/recommendations which more or less say "We're not saying you 'shouldn't' do an epidural/spinal if low but we're also not saying there's a cutoff.....which in my book is near useless.

I understand why cutoffs are problematic but at this point I want a sense of what the community is doing.

If it's stable? Personally, not really. But I'm not sure if my group would have my back at anything less than 75k, so that's my current line in the sand.

 

[patriot6]

50K SAB, 75K epidural

 

[dabears505]

Yes, but it increases by 10k every hour after 2300 until 0700 at which point it resets.

What happens if 7 am relief for whatever reason won't arrive til 8 that day? Is it still reset?

 

[deleted162650]

What happens if 7 am relief for whatever reason won't arrive til 8 that day? Is it still reset?

Sure, I don’t mind placing an epidural after 0700.

 

[pgg]

I'm sure this topic is discussed elsewhere on the forum but since this is an OB thread I thought I'd bring it up.

Platelet count.

Do you have a "too low" cutoff? I know there's literature/recommendations which more or less say "We're not saying you 'shouldn't' do an epidural/spinal if low but we're also not saying there's a cutoff.....which in my book is near useless.

I understand why cutoffs are problematic but at this point I want a sense of what the community is doing.

Absent a bleeding history or zebras or bad things like HELLP, acute fatty liver of pregnancy, DIC, TTP, ITP, etc ... a platelet count in the 50-100K range is probably benign gestational thrombocytopenia and neuraxial is fine. Of course the catch is your confidence in your diagnosis, and I've yet to meet a dual trained hematologist anesthesiologist.

To actually answer your cutoff question with my own numbers -

I'd transfuse platelets below these thresholds
- 20K platelets for a vaginal delivery
- 50K for a section under GA
- 75K for a section under regional

I would never transfuse platelets for elective labor analgesia. I wouldn't go below 75K for an epidural. I might say no below 100K if the patient looked off or difficult. I might opt for a single shot labor spinal in a multip whose delivery was assuredly soon.

 

[Twiggidy]

Some interesting responses. We at least once a month or two get a patient with a platelet count like 1k below our established “cutoff” and the sob story begins and we circle the department asking who would do what

 

[DrOwnage]

75k for epidural, 50k for spinal (24-25g needle). If etiology is preeclampsia, that platelet count has to be within the past 4 hours.

 

[Mman]

50k for spinal (24-25g needle)

for the sake of conversation, if you could not get it with a 24 or 25 g needle do you just go to GA then instead of trying a 22? How many needle passes are you willing to make?

To me the biggest difference between an epidural and a spinal isn't necessarily the gauge of the needle, it's that the epidural is going to leave a catheter behind that has to be removed at some point.

 

[DrOwnage]

Well yeah because the 22g needle I use is a cutting needle and causes a lot more trauma. Not to mention at the point when its difficult I'm usually bending it at acute angle to sneak past osteophytes or processes. The catheter staying there is ok. I've transfused platelets for removal of a catheter in the HELLP patient who's count was sluggish to recover.

 

[Mman]

Well yeah because the 22g needle I use is a cutting needle and causes a lot more trauma. Not to mention at the point when its difficult I'm usually bending it at acute angle to sneak past osteophytes or processes. The catheter staying there is ok. I've transfused platelets for removal of a catheter in the HELLP patient who's count was sluggish to recover.

what is the difference in trauma to an epidural vein from say a cutting needle vs a pencil point needle? It's a vein, it breaks open easily from any sort of needle.

 

[DrOwnage]

If you use enough 22g spinal needle you will see a higher incidence of some blood in the needle. Needle is bigger and the sides are sharp. I know it sounds stupid but I think it makes a difference.

 

[deleted162650]

Well yeah because the 22g needle I use is a cutting needle and causes a lot more trauma.

You’re using a 22g cutter in the obstetric population??

 

[DrOwnage]

You’re using a 22g cutter in the obstetric population??

Maybe once in the past 9 months in OB. More so just making a point to be careful/would not use in thrombocytopenic patients

 

[parcus]

Used to do most OB spinals with a 27 G W needle. Sometimes would switch to 25 G if we encountered difficulty. Would never go for a 22G.