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.

You are called to labour ward to place an epidural in a nulliparous woman who is obviously extremely distressed in pain. After you sit her up to clean her back you notice she has a long scar running down the middle of her back. Between contractions she tells you she had surgery as a teenager to straighten her back.....what does this mean? Hi Everyone, Graeme regularly teaches this topic to our anaesthesia trainees and I was surprised to realise that we haven't done a podcast on this already. Join us as we discuss scoliosis, spina bifida, spinal surgery and other assorted spinal issues.

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 References Evaluation 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. 

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!

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!

Hi everyone, Welcome to part 1 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! Reference - Fishbane Reaction Safety of Intravenous Iron Following Infusion Reactions Stojanovic et al The Journal of Allergy and Clinical Immunology: In Practice Volume 9, Issue 4, April 2021: 1660-1666 - A great paper discussing the different types of reactions to i.v. including the Fishbane reaction and how they were managed in over 13000 iron infusions at the Alfred Hospital in Melbourne. Unfortunately it is an Elsevier publication and you will need some sort of institutional access to read it in full. Where is the iron in our body?

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! References https://resus.me/understanding-elevated-lactate/ https://youtu.be/TuvKcplVQLg

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 pressure increased to 130bpm and 160/100 mmHg. A rapid survey of previously administered medications revealed tranexamic acid 300mg was accidentally injected into the subarachnoid space instead of 15mg of hyperbaric bupivacaine." - case report 2021 Graeme and I sit down to do a deep dive on the serious topic of accidental neuraxial administration of tranexamic acid which may have up to 50% mortality. We discuss two papers which summarise over 40 published case reports of spinal administration and one case report of accidental epidural administration. Join us as we discuss the pharmacological mechanism of toxicity, proposed treatments and methods to minimise the risk of this occurring in the first place. References Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. S. Patel, B. Robertson, I. McConachie Anaesthesia. 2019 Jul;74(7):904-914. - Open access Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia: A narrative review of 22 recent reports. S. Patel Eur J Anesthesiol 2023 May 1;40(5):334-342. - This article is not open access. Accidental administration of tranexamic acid into the epidural space: a case report. C. Pysyk, L Filteau Can J Anaesth 69, pages 1169–1173 (2022) - open access Tranexamic acid-associated seizures: Causes and treatment. I.Lecker et al. Ann Neurol 2016 Jan;79(1):18-26.

Hi Everyone, Join Siv and I as we sit down to discuss a couple of interesting obstetric related topics. The first is the pharmacology around the choice and strength of local anaesthetics used in epidural analgesia - thanks Siv. The second part we discuss a very large pragmatic study in the New England Journal of Medicine of 11000 women studying the use of tranexamic acid as a prophylaxis during caesarean surgery (elective and emergency). Spoiler alert it didn't show any difference (death or transfusion). Thanks Siv! References Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery Pacheo et al N Engl J Med 2023; 388:1365-1375 Minimum local analgesic concentration of local anaesthetics. Malachy Columb, Iain Gall Continuing Education in Anaesthesia Critical Care & Pain, Volume 10, Issue 4, August 2010, Pages 114–116 Determination of the Minimum Local Analgesic Concentrations of Epidural Bupivacaine and Lidocaine in Labor. Columb, Malachy O. FRCA; Lyons, Gordon FRCA. Anesthesia & Analgesia 81(4):p 833-837, October 1995.

Hi Everyone, This week we are joined by Dr Anastazia Keegan an obstetric haematologist and the head of Haematology at our Women's hospital here in Western Australia. Join us as Anastazia educates us about congenital bleeding disorders in pregnancy - the common ones, Von Willebrands disease and haemophilia - and how to approach a woman with one of the many uncommon ones (which working in a tertiary referral centre are more common than you would expect). Thanks for all the great advice and insights - we look forward to having Anastazia back in the near future for the lowdown on some more really important haematological conditions we encounter in women's health. References Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210 (7): Online Bleeding Assessment Tool ISTH-BAT

Hi Everyone, This is part 2 of a discussion (see the previous episode for part 1). We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association). We discuss the highlights of this two day meeting and some of the takeaway learning points. Thanks to Matt Rucklidge and Jane Brown who organised the speakers – an absolutely amazing line up of compelling speakers and topics! Apologies for the audio quality – we didn’t have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music…… Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year – see the links below: References Challenges and Choices in Obstetric Anaesthesia – Sydney Convention centre May 3-4 2023 Obstetric Anaesthetist’s Association OAA-UK – see links to their annual meetings Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art Illustrated Edition. Dr Allan Cyna

Hi Everyone, We have just returned from the Obstetric Anaesthesia Special Interest Group Satellite meeting held on May 3-4. I sat down two days after the meeting with Dr Matt Rucklidge (the convenor of this meeting and a colleague here at KEMH) and Prof Nuala Lucas one of the keynote invited speakers from the UK who is the president of the OAA UK (Obstetric Anaesthesia Association). We discuss the highlights of this two day meeting and some of the takeaway learning points. Thanks to Matt Rucklidge and Jane Brown who organised the speakers - an absolutely amazing line up of compelling speakers and topics! Apologies for the audio quality - we didn't have the usual microphones and had to record in a side room at the Sydney Convention centre at were unable to get away from the background elevator music...... Nuala flew straight from Sydney back to the OAA annual meeting this year being held in Edinburgh. If anyone is interested in attending any excellent Obstetric Anaesthesia meetings the OAA hold two very well regarded meetings held every year - see the links below: References Challenges and Choices in Obstetric Anaesthesia - Sydney Convention centre May 3-4 2023 Obstetric Anaesthetist's Association OAA-UK - see links to their annual meetings Moran, NF, Bishop, DG, Fawcus, S, Morris, E, Shakur-Still, H, Devall, AJ, et al. Tranexamic acid at cesarean delivery: drug-error deaths. BJOG. 2023; 130(1): 114– 117. https://doi.org/10.1111/1471-0528.17292

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! References Guideline for the Prevention, Diagnosis and Management of Hyponatraemia in Labour and the Immediate Postpartum Period - GAIN Northern Ireland March 2017

Hi Everyone, In our tertiary women's hospital here in Perth we use remifentanil PCA in labour approximately 15 times a year - and we are told that in Australian terms this is considered a "heavy user" of this labour analgesic technqiue. This week I sit down with Mike Jamison an anaesthetic fellow from Belfast spending a year with us here in Perth. When he arrived in WA we quickly learned from him that remifentanil PCA is commonly used for labour analgesia in Northern Ireland with one unit he worked in having prescribed this technique for more than 11,000 women. We sit down to have a deep dive into the use of remifentanil PCA in labour in Northern Ireland. What aspects of their approach have led it to become such a commonly utilised technique? What is their recipe? How do they prescribe it, how do they monitor the women and how is this technique now viewed amongst the obstetric, midwifery and wider Northern Irish community! If you are attending the upcoming Obstetric Anaesthesia satellite meeting in Sydney in a few weeks - come along to hear Mike talk on this in person! References Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. The Lancet volume 392, p662-672, AUGUST 25, 2018 Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years' experience. H Murray, P Hodgkinson, D Hughes. Int J Obstet Anesth 2019 Aug;39:29-39

You are referred a patient who needs urgent surgery and the obstetrician tells you she has some obscure medical condition which you have never heard of before. Does her condition have any implications for the safe conduct of anaesthesia? How can you find out in a timely manner what the specific anaesthetic issues are and what anaesthetics have been used safely by others in these patients before? Hi everyone, This week I am joined by Siv and Sarah to discuss this tricky situation and to give a free plug for the website orphananesthesia.eu a site started by the German society of anaesthesiology and now contributed to by anaesthesia providers from all over the world to help with these difficult patients. Correction: In the podcast we referred to Stoelting's textbook - this text is actually titled "Anesthesia and co-existing disease" - but not dedicated specifically to rare or uncommon disorders. A more relevant text would have been Fleischer et al "Anaesthesia and uncommon diseases". References https://www.orphananesthesia.eu/en/

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! References Preventing 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.

(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" Check the patient's oxygen sats whilst supine - pre induction (use to plan target sats intra & post) Individualise FiO2 for pre-oxygenation and not necessarily 100% for most (usually 80%) Have the APL valve at around 5cm H20 when preoxygenating Head-up / ramped (to maintain FRC) Recruitment manoeuvre after intubation and before pneumoperitoneum - use a machine technique not hand recruitment. Start with a PEEP 5-8cm H20, individualise during the case - may need higher whilst head down and pneumoperitoneum. Small Tidal Volumes (TV) 5-8ml/kg of ideal body weight - (obese patients don't get bigger TV's) Keep FiO2 0.95 Don't use 100% O2, Aim FiO2 < 0.8 If breathing on manual ventilation setting have APL valve at 5-10 to maintain PEEP Squeeze bag as extubating Immediately post extubation place face mask with APL still at 5-10 Be cautious / avoid excessive opioids that will suppress respiratory drive in PACU References A 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)

Hi everyone, This week three of us sit down to discuss a great review article (and topic) - the use of TIVA (total intravenous anaesthesia) for GA caesarean surgery. For many the classic technique for a GA caesarean has been thio / sux tube then volatile & nitrous oxide. In recent years many aspects of this have started to change with propofol probably more commonly used as the i.v. induction agent and now in many cases rocuronium is used in preference to suxamethonium. Now with the much increased use of TIVA across anaesthesia practice there is a renewed interest in it's role for women having caesarean surgery and GA for management of postpartum haemorrhage. Join us as we discuss this article. What do we mean by TIVA? What are the potential benefits? (uterine tone, recovery, PONV) and are there risks? (awareness, fetal depression, over sedation). It is fair to say there has not been a lot of high quality research done on this topic and there are more questions than definitive answers, but this article does well to summarise the issues and what we do know. Informal Twitter Poll result from Parita!: References The role of total intravenous anaesthesia for caesarean delivery. Y. Metodiev, D.N. Lucas IJOA April 08, 2022 Comments on above article - M.Paech IJOA June 28, 2022

Hi Everyone, You receive a phone call at 2am from a junior colleague who tells you that they are managing a code blue caesarean section and in the confusion of urgently administering a number of different medications they have just accidentally injected 10ml of cephazolin into the epidural catheter instead of the intravenous tubing. They are understandably upset and worried. (* This is a hypothetical scenario). What are wrong route errors? How common are they? How do they happen? Article from 2012 - "The US Pharmacopeia, the largest information source of tube misconnection related errors, has received 1600 reports of epidural to central or peripheral intravenous misconnections since 1999." What is NRFIT and how will this help improve patient safety? When is it coming? - It is already here and will probably coming to your health service soon. Many hospitals around the world including all of Japan have already changed over and a few sites in Australia / NZ have also now introduced NRFIT. Join Graeme and I as we discuss the issue of wrong route errors, and what you need to know about NRFIT, as well of course a few bad Xmas jokes! LINKS Reducing Risk of Epidural-Intravenous Misconnections - APSF Newsletter Winter 2012 Challenges when introducing NRFit™ at a tertiary hospital in Japan International Journal of Obstetric Anesthesia, 2022-02-01, Volume 49, Article 103244 . This article is behind Elseviers firewall but you should be able to access it through the ANZCA library or your own hospitals if you are lucky enough to have these available. NRFIT Pajunk Stay connected GEDSA NRFIT website

Hi everyone, This week Graeme and I sit down for the first time in nearly a year and do a bit of a deep dive on the use of nitrous oxide as an analgesic in labour. We drop a few dad jokes, discuss the history of inhaled analgesics, nitrous oxide use around the world, the evidence, the environmental concerns and other interesting anecdotes. Do you have nitrous oxide on labour ward in your part of the world? Send us a comment and let us know! Enjoy LINKS ANZCA Blue Book 2021 (Australasian Anaesthesia) - go to page 183 Developments in labour analgesia and their use in Australia 2015 Safety and Utility of Nitrous Oxide for Labor Analgesia APSF Journal June 2020

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 as well as have all the "annoying lines and tubes removed from my arms!". Unfortunately she is still on 3ml/hr of a metaraminol infusion and everytime the nurse tries to wean it off her BP drops to 70/45..... Is there anything you can do? Hi everyone, This week Rheily and I discuss the pharmacology of oral midodrine a alpha adrenergic agonist useful as an oral systemic vasoconstrictor. Join us as we discuss the ins and outs of using oral midodrine - please leave us a comment if you have some experience or tips to share! USEFUL LINKS Australasian Anaesthesia 2019 (Blue Book) Article - go to page 101

Hi everyone, This week Sneha leads a discussion with both Matt and myself where we take a deep dive into how to actually perform an epidural blood patch. Even though you can't really classify this as an uncommon procedure, as individuals we probably don't do very many and it is hard for most of us to become experienced and "expert" (whatever that is defined as). We discuss the evidence, the effectiveness, the practical considerations and some of the common problems / difficulties which may be encountered. Thanks Sneha (for organising and leading this episode) and of course you too Matt! LINKS Epidural blood patch: A narrative review - Anaesthesia Critical Care & Pain Medicine October 2022 Treatment of obstetric post-dural puncture headache. Part 2: epidural blood patch International Journal of Obstetric Anesthesia 2019

Welcome to this podcast, the tenth in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to neuraxial anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). Thanks Shilpa, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery part 1 10 - Neuraxial anaesthesia for Caesarean Delivery part 2

Welcome to this podcast, the ninth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to neuraxial anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). Thanks Shilpa, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery part 1 10 - Neuraxial anaesthesia for Caesarean Delivery part 2 https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/

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 real haemorrhage cases - a follow up on our promise from the earlier episode 97 where we discuss the basics of managing obstetric haemorrhage. Thanks Graeme, Shilpa and Matt! Links 097 Obstetric haemorrhage https://youtu.be/rc9BYcIhamA MBRRACE-UK - Maternal mortality and morbidity reports UK https://youtu.be/nqRBbXxzX6Q

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 topic of maternal sepsis. Join us as in this second episode where we discuss amongst many things. antibioticsfluids & vasopressorsmulti-organ dysfunctionsource controlanecdotes & tips Thanks Sneha & Jess! If you haven't already listen to episode one first: https://www.obsgynaecritcare.org/098-maternal-sepsis-with-jess-and-sneha-part-1/?preview=true LINKS “Sepsis in Pregnancy” Burlinson et al – International Journal of Obstetric Anaesthesia 2018 “Maternal sepsis” Filetici et al – Best Pract Res Clin Anaesthesiol 2022

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 topic of maternal sepsis. Join us as in this first episode where we discuss amongst many things the recent changes in how sepsis is defineddetection and recognition in pregnancycommon micro-organisms Thanks Sneha & Jess! LINKS "Sepsis in Pregnancy" Burlinson et al - International Journal of Obstetric Anaesthesia 2018 "Maternal sepsis" Filetici et al - Best Pract Res Clin Anaesthesiol 2022

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 and common obstetric emergency. Thanks Shilpa, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 - Neuraxial anaesthesia for Caesarean Delivery Useful Links https://youtu.be/rc9BYcIhamA https://www.obsgynaecritcare.org/rotem/

Welcome to this podcast, the seventh in our series of obstetric anaesthesia basics. Join us for this the second part of a conversation where we discuss all things relating to general anaesthesia for Caesarean section. Due to it’s length we have split this discussion into two parts – who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). It makes easier listening if you listen to episode one first! Thanks Laura, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/

Welcome to this podcast, the sixth in our series of obstetric anaesthesia basics. Join us for this the first part of a conversation where we discuss all things relating to general anaesthesia for Caesarean section. Due to it's length we have split this discussion into two parts - who would have thought we could talk for so long about this! (I thought it would only be one episode and was surprised what we teased out). Thanks Laura, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

Welcome to this podcast, the fifth in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss eclampsia, pre-eclampsia, hypertensive disorders and the specific issues relating to provision of obstetric anaesthesia. Thanks Laura, Graeme & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

Welcome to this podcast, the four in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss the approach to a woman with a suspected or known post dural puncture headache. This follows our previous discussion of the incidence, significance and management of accidental dural punctures & intrathecal catheters, which you may want to listen to prior to this episode. Thanks Laura, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

Welcome to this podcast, the third in our series of obstetric anaesthesia basics. Join us for this conversation where we discuss the incidence, significance and management of accidental dural punctures & intrathecal catheters. Thanks Laura, Matt & Roger! BASICS OF OBSTETRIC ANAESTHESIA The "Basics of Obstetric Anaesthesia" is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

In Part 2 of epidural analgesia in labour we discuss common problems, difficulties and how to troubleshoot issues in our epidurals on labour ward. Thanks again Matt & Shilpa! BASICS OF OBSTETRIC ANAESTHESIA The “Basics of Obstetric Anaesthesia” is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

We discuss the basics involved in epidural analgesia for labour. Join us in the next podcast where we will discuss common problems, pitfalls and how to trouble-shoot issues. Thanks Matt & Shilpa! BASICS OF OBSTETRIC ANAESTHESIA The "Basics of Obstetric Anaesthesia" is a short series of podcasts, where we aim to discuss in a conversational manner the basic topics you will need to understand if you wish to practice obstetric anaesthesia. These will be especially useful to anaesthesia trainees new to obstetric anaesthesia but also may appeal to experienced practitioners wanting a refresher of the basics in this subspecialty area. 1 – Epidural analgesia in labour part 1 2 – Epidural analgesia in labour part 2, pitfalls and troubleshooting 3 – Accidental dural puncture and intrathecal catheters 4 – Post-dural puncture headaches and management 5 – Pre-eclampsia, eclampsia and hypertensive disorders 6 – General anaesthesia for Caesarean Delivery part 1 7 – General anaesthesia for Caesarean Delivery part 2 8 – Obstetric Haemorrhage 9 – Neuraxial anaesthesia for Caesarean Delivery https://www.obsgynaecritcare.org/podcast-series-on-the-basics-of-obstetric-anaesthesia/embed/#?secret=Ut7cFWuyJp#?secret=NAwEYLzf8U

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 BP is 220/110, her heart rate 120/min, oxygen sats 88% despite high flow oxygen. She has a history of hypertension, diabetes and amphetamine abuse. You grab the nearby obstetric ultrasound (because it is there) and quickly scan her lungs with the curvilinear probe - all the lung fields are full of B-lines..... Hi everyone join Graeme and I as we discuss the acute management of this condition, variously known as SCAPE (sympathetic crashing acute pulmonary oedema), flash pulmonary oedema, or hypertensive pulmonary oedema. Links Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group. J Card Fail. 2016 Aug;22(8):618-27 A critical appraisal of the morphine in the acute pulmonary edema: real or real uncertain? J Thorac Dis. 2017 Jul;9(7):1802-1805.  https://emcrit.org/pulmcrit/scape-2/#:~:text=SCAPE%20%28Sympathetic%20Crashing%20Acute%20Pulmonary%20Edema%29%20is%20a,SCAPE%20in%20articles%20and%20chapters%20about%20heart%20failure.

A pregnant woman at 32/40 weeks gestation is rushed into your theatre for a code blue caesarean because of fetal distress. The team tell you that she has been in hospital for the last 6 weeks with Guillain Barre syndrome and has only just got out of ICU where she needed respiratory support for a number of weeks. What sort of anaesthetic are you going to give? Why is the traditional thio / sux / tube likely to go badly? If you inject local anaesthetics into her neuraxium what response will you expect from her already damaged nervous system? Will the drugs cause any further damage? What about breathing and swallowing problems afterwards? Hi everyone, This week I am joined by Dr Shilpa Desai, an anaesthetic consultant colleague and we discuss how to handle this rare but tricky group of patients and share a few dodgy dad jokes on the way! References https://resources.wfsahq.org/atotw/guillain-barre-syndrome/ Guillain Barre Syndrome - BJA Cardiac arrest after succinylcholine administration in a pregnant patient recovered from Guillain-Barré syndrome

A nulliparous woman is admitted to labour ward in established labour, she is in a lot of pain and asks for an epidural. The team note that a full blood count taken 2 days ago showed a platelet count of 48. Is this a real thrombocytopenia? What are the causes of thrombocytopenia in pregnancy? How are they treated? What about epidural or spinal anesthesia? Will she bleed? What if it falls further and she needs platelets? Hi everyone, Welcome to part 2 of our discussion on thrombocytopenia and platelets in pregnancy with Dr Simon Kavanagh a consultant haematologist. As this is a conversation split into two - if you haven't already please listen to part 1 first (see link below): Thanks Simon! https://www.obsgynaecritcare.org/thrombocytopenia-in-pregnancy/

A nulliparous woman is admitted to labour ward in established labour, she is in a lot of pain and asks for an epidural. The team note that a full blood count taken 2 days ago showed a platelet count of 48. Is this a real thrombocytopenia? What are the causes of thrombocytopenia in pregnancy? How are they treated? What about epidural or spinal anesthesia? Will she bleed? What if it falls further and she needs platelets? Hi everyone, This week I have a new guest on the show Dr Simon Kavanagh a consultant haematologist and we do a two part deep dive into thrombocytopenia in pregnancy, what are the causes, what to do and who to call! (hint they specialise in diseases of the blood.....) Thanks Simon! References HOW Collaborative position paper on the management of thrombocytopenia in pregnancy - ANZJOG Jan 2021 This is published by Wiley and you may need to access it via your institution / library

You are called to see a 31 yr old woman on the ward who is 8 hours postop after a diagnostic laparoscopy to investigate her longterm chronic pelvic pain. The nurse treating her is concerned because she is still complaining of pain despite many analgesics, however she is more concerned by the patient's increasingly erratic behaviour and agitation. Her heart rate is 108/min, NIBP 155/95, she appears sweaty, temp = 38.9C, appears restless and has some noticeable tremor. When you examine her she has very brisk reflexes and three beats of clonus in her ankles. Glancing at her med chart you see she is usually on desvenlafaxine 50mg/day, tramadol 100mg BD, and admits to using methamphetamine recreationally. Join Graeme and I as we discuss a rational approach to this sort of scenario, share some real life anecdotes and trade a few more dodgy dad jokes. Differential diagnoses (don't miss these)Deeper dive into SS syndrome, and NLMS References Tutorial of the Week 2010 Serotonergic Syndrome Serotonin Syndrome in the Perioperative Period BJA Education 2020

You are called to review a 35yr old woman at 36 weeks in labour ward who has had a couple of "funny turns" in the last 15 minutes where she became unresponsive and then seemed confused for a few minutes after. When you get there they tell you she is being induced with cervidil for premature rupture of membranes but she is not in active labour. Because of the PROM she has been started on erythromycin. She has also been unwell with hyperemesis most of the pregnancy but has been vomiting a lot over the last 2 days and has received a lot of medications to try and get on top of it including, ondansetron, droperidol, famotidine and maxalon - with only limited effect. She looks pretty thin and she says she has had a lot of trouble with her weight / nutrition because of her chronic nausea. The team have done some observations on her - she has a heart rate of 57/min, BP 100/55, she is afebrile and not tachypneic. At this stage the team thinks maybe she is fainting because she is a bit dehydrated but decide to send off some bloods and to do an ECG "to make sure there is nothing else going on". Her bloods come back and her potassium is only 2.2 and she is anaemic Hb 95. The ECG shows the following - what's wrong? (Image borrowed from LITFL - Hypokalaemia ECG changes • LITFL • ECG Library) Suddenly she passes out again whilst the ECG is attached, what are you going to do? Image borrowed from LITFL - Polymorphic VT and Torsades de Pointes (TdP) • LITFL Join Graeme and I as we discuss another fascinating topic after having a couple of patients recently with this challenging but fascinating syndrome.....

"Doctor did you know your next patient is a micro alert ?" What does this mean? Do we have to suit up as if there has been an outbreak of Ebola? Will Cefazolin 2g suffice? I just pushed in the vancomycin as recommended - why is the patient now on noradrenaline????? This week I am joined by Jodie Jamieson - an anaesthetic colleague and Claire Kendrick a pharmacist here at KEMH. We discuss the most commonly encountered microbiology alerts, especially MRSA and important safety points concerning some of the less commonly encountered antibiotics. Thanks Jodie and Claire! Note these are the microbiology alerts used in Western Australia - they will not be the same in other parts of the world! USEFUL LINKS Therapeutic Guidelines - https://www.tg.org.au KEMH Clinical Guidelines for health professionals - https://www.kemh.health.wa.gov.au/For-health-professionals/Clinical-guidelines/OG

Hypothetical Case: A gynaecologist contacts you as the duty anesthetist to book an emergency laparoscopic oophorectomy. They tell you that the patient is a young woman who is currently intubated and ventilated on the intensive care unit after presenting 2 days earlier with a complex neurological syndrome, complicated by seizures requiring intubation. The surgeon tells you the ICU team have done some investigations, including an ultrasound demonstrating a complex ovarian mass, and CSF on a lumbar puncture positive for anti-NMDA receptor antibodies. What is Anti-NMDA receptor encephalitis? Why is it associated with gynaecology? When & how was it first discovered? Join Graeme and I as we discuss the ins/outs of this fascinating condition and share a few personal anecdotes of patient's we have encountered with this project. LINKS Pregnancy outcomes in anti-NMDA receptor encephalitis Acute psychiatric illness in a young woman: an unusual form of encephalitis MJA 2009 Josep Dalmau: exploring the paraneoplastic syndromes An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models

Hi everyone, A few weeks ago I sat down again with one of current trainees Sneha to discuss the interesting subject of the use smartphone applications in anaesthesia, and her latest offer to star in Survivor! LIST-OF-ANAESTHESIA-APPSDownload

Hi Everyone, After over 2 months off Graeme and I back for our first podcast of 2021. In this episode we discuss some news and then dissect the recently published study which analysed the narrative descriptions of the 483 maternal deaths which occurred in the WOMAN study. The WOMAN trial was a large randomised study of 20000 women suffering postpartum haemorrhage comparing tranexamic acid and placebo published in 2017. There were 483 maternal deaths in this study and each death was accompanied with a short narrative description of the circumstances surrounding the death. This study discusses some of the common themes which are encountered frequently in these narratives. LINKS The WOMAN Study 2017 - Lancet website The WOMAN trial: clinical and contextual factors surrounding the deaths of 483 women following post-partum haemorrhage in developing countries

Hi everyone, Graeme and I recorded this episode way back just before Christmas but because of technical issues here it is a little bit late! Disclaimer neither Graeme or I have any claim to being experts in exam technique but we hope that you find our opinions / advice of some use. Also my answers to these questions were easier for me than real life vivas because I knew in advance what the questions were going to be! Good luck to everyone sitting exams in 2021!

Hi Everyone, This week I am joined again by Mike and we discuss this fascinating syndrome of pregnancy, the management of which many of us have had drilled into us for many decades. Although this is a real syndrome which has been recognised for many years and has many serious potential consequences there are many controversies regarding it's physiology and treatment. In recent years advances in imaging technology and recent studies have questioned some of practices which were taught as if they were dogma...... How far can we tilt the operating table in theatre and does it really help? Compression of the aorta - really? Thanks Mike LINKS The Aortocaval Compression Conundrum - Analgesia and Anesthesia 2017 https://youtu.be/Y2T4MLiQTrM

Hi Everyone, This week I am joined on the show with a new guest, consultant anaesthetist Dr Chris Mitchell. Chris is a colleague who also used to work with us at our women's hospital and is already famous for his range of USS regional anaesthesia needles (now manufactured by pajunk). Today we discuss the issue of the adverse environmental effects of our profession. In particular we focus on anaesthetic gases and what we can do to make a difference. LINKS British Journal of Anaesthesia 2020 - Environmental sustainability in anaesthesia and critical care

Hi Everyone, Thanks to Mason Habel from Northern Health in Victoria, who contacted us a few months ago and suggested this topic to us. Join Graeme and I as we try to tackle this topic in a comprehensible manner. We do jump around a little bit, chasing anecdotes, interesting historical facts and the occasional dodgy dad joke but hopefully we get there in the end! LINKS 054 – Neurological injuries after childbirth and neuraxial anaesthesia. 053 – Complications after central neuraxial blocks in obstetric anaesthesia a discussion with Graeme 046 – Managing a patient with a postdural puncture headache PDPH with Dr Matt Rucklidge

Hypothetical case: You are called to a code blue medical on the gynaecology ward. A patient in her late 60s has collapsed in the bathroom. You are told she was admitted earlier that day for investigation of a probable pelvic cancer. She is conscious, has a heart rate 130/min, NIBP 90/45, SPO2 94% on hudson mask, and is mildly SOB with a respiratory rate 30/min. This patient undergoes investigation and is diagnosed with a large pulmonary embolism. She deteriorates suddenly with the following vitals: groaning, HR 145/min, NIBP 60/35, SpO2 85%, Respiratory rate 35/min. What is the physiology and what are the principles behind the resuscitation of a patient with an acute right ventricular emergency like this? Fluids? Vasopressors? Inotropes? Thrombolysis? Intubation? Pulmonary vasodilators? Join Graeme and I as we discuss this particularly challenging scenario which can be both hard to diagnose and resuscitate. There are some important and critical differences to other common causes of deterioration, and serious traps to be aware of and avoid. Whilst educating myself on this topic I realised that I wasn't as up to speed on this as I thought I was! Thanks to the following resources which I have listed below which I strongly recommend: USEFUL LINKS EMCrit 272 – Right Heart Failure with Sara Crager PulmCrit- Nebulized nitroglycerin: The stealth pulmonary vasodilator hiding under your nose?

Hi everyone, This week I am joined by Matt & Graeme to discuss induction drugs and adjuncts used in general anaesthesia for caesarean delivery, with a few obligatory dad jokes thrown in at the end if you make it that far! Hypothetical cases we discuss: 1 - Healthy woman rushed to theatre with cord prolapse and fetal compromise 2 - A woman with severe preeclampsia needs urgent caesarean delivery because of fetal compromise. She has a platelet count of 18, and a BP of 210/120. 3 - A woman ruptures her uterus attempting a VBAC and arrives in theatre with a heart rate of 170/min and BP of 60/40 USEFUL LINKS The future of general anaesthesia in obstetrics BJA Education 2016

Hypothetical patient: You get called by an anaesthetic registrar to come and help them with a woman in labour ward. They tell you that they have been struggling for a number of hours now to get a woman comfortable. They have placed three epidurals and topped them up aggressively with generous doses of the usual bupivacaine and fentanyl medications but none of them seem to have been effective. The woman told them that she has had similar problems in the past with dental procedures and minor skin procedures when younger - she also states she has Ehlers-Danlos syndrome. Hi Everyone, This week I am joined by Fionn - a WA anaesthetic trainee currently working with us here. We discuss the fascinating (but distressing) syndrome of resistance to local anaesthetics. Is it real? (yes) How common is it - and what do we know about it? LINKS https://www.bbc.com/future/article/20170106-the-people-who-cant-go-numb-at-the-dentists https://www.hypermobility.org/local-anaesthetic Resistance to local anesthesia in people with the Ehlers-Danlos Syndromes presenting for dental surgery

You receive a call from an obstetrician: "I have a term patient booked for induction of labour this morning. She had an MRI of her brain 4 years ago after a car accident and was told she has an Arnold-Chiari malformation. She is very keen to have an epidural - can she have one?" Hi everyone, This week Graeme is back and we sit down to discuss Arnold - Chiari malformations and having a baby - why all the fuss and controversy? References Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study Management of parturients in active labor with Arnold Chiari malformation, tonsillar herniation, and syringomyelia https://www.orphananesthesia.eu Ghaly Chiari malformation decision guide - see article above

You are called to a code blue medical on labour ward. A woman who has been in labour attempting a VBAC has just collapsed whilst pushing during the second stage. She is unresponsive, not breathing and looks "bad". This week I am joined by my two colleagues, also consultant anaesthetists, Dr Emelyn Lee and Dr Lip Ng. Join us for this interesting conversation where we discuss all things relating to cardiac arrest in pregnancy! Links https://resus.org.au/

Hi Everyone, This week I sit down again with Graeme. We discuss WA's isolation & covid bubble, exchange a few crap jokes and have a go at the thorny topic of shivering under neuraxial anaesthesia. Big thanks to everyone who helped with the OSCAR trial all those years ago, Yelena for teaching me a new trick to stop shivering and to Dr Tim Pavy for giving me two weeks leave to write up my thesis on shivering! LINKS The OSCAR trial - prophylactic ondansetron does not prevent or decrease the severity of shivering under spinal for Caesarean.

Hi Everyone, This week is our first episode of our journal club to discuss interesting recent relevant research papers. We are hoping to do this on a regular basis interspersed amongst the other regular episodes where we choose a topic and explore it in detail. In this inaugural episode I am joined by a couple of colleagues who have both been on the podcast before. We have decided to choose articles from IJOA - the International Journal of Obstetric Anaesthesia - a journal devoted to obstetric anaesthesia, critical care and perinatology. Prof Mike Paech is the chief editor, has been on it's editorial board almost since it was first started in the 1990s and Dr Matt Rucklidge has also been a reviewer for the journal for a number of years now. Mike explains the history of the journal and shares some insights of what it is like being a chief editor, and then we discuss four interesting articles from recent editions. REFERENCES International Journal of Obstetric Anaesthesia https://www.obstetanesthesia.com/ 1.Rocuronium Versus Suxamethonium for Rapid Sequence Induction of General Anaesthesia for Caesarean Section: Influence on Neonatal Outcomes 2. Lower-limb Neurologic Deficit After Vaginal Delivery: A Prospective Observational Study

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 this is her third attempt to seek help over a number of years. She initially sought help for amenorrhoea after her second delivery and was started on oestrogen / progesterone tablets. The second doctor gave her a diagnosis of postpartum depression after eliciting a history of anxiety, tachycardia and feelings of stress and started her on an antidepressant. However the medication didn't help and she tapered them off and didn't return. On close questioning she recounts that her first delivery was uncomplicated but the second was an emergency caesarean after failure to progress and fetal distress. The surgery was complicated by blood loss of 4 litres and she remembers being told by staff "that the blood was coming out as fast as it was going in". She spent a number of days in the HDU / ICU and her child was bottle fed because she had difficulty establishing breastfeeding due to the traumatic events. Join Graeme and I again as we discuss this important but rare complication of pregnancy. References Diagnosis and Treatment Challenges of Sheehan's Syndrome Sheehan's syndrome in modern times: a nationwide retrospective study in Iceland QUIZ Which of these is a doctor and which is a serial killer? - and who are they!

Hi Everyone, This week on the podcast I am joined by Dr Andi Atkinson one of the obstetric and gynaecology trainees here in WA. A few years ago Andi took time off during her training to spend time working in Africa for MSF on two separate occasions and we sat down to record an interview where she explains the processes involved in working with MSF and reflects on some of her experiences during her missions. Andi is still training here in WA but tells me she intends to work again for MSF sometime in the near future. Thanks for sharing your stories Andi! Links MSF Australia https://msf.org.au/

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 some blood testing and find she has a BP 150/95, mildly hyperreflexic and bloods showing a Hb107, Plts 88, schistocytes on the film, raised AST / ALT /LDH and bilirubin. Hi Everyone, Acknowledging that we are still in the midst of a world wide pandemic we hope you are all safe. This week we thought it would be nice to take a break from COVID related matters (which we are sure like us has invaded most of your minds over the last few months) and turn to a fascinating obstetric critical illness. Join Graeme and I as we discuss this interesting and serious pregnancy related condition. What causes this condition?What do they die from? What are the important differential diagnoses? How do we manage them? We also share a few sh***e dad jokes, reminisce about ANZAC Day, the COVID pandemic and have another crack at one of our quizzes! Doctor or serial killer? Is This Person a Doctor or Serial Killer?? Leave a comment below Bonus Points available if you can tell us their name!

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 have COVID-19. Is pregnancy a risk factor for worse disease severity?What is the appropriate PPE for women in active labour? Is active labour an aerosol generating procedure?What about the use of inhaled (and therefore exhaled) nitrous oxide in these women?What about the need for emergency or urgent procedures such as caesarean sections or post partum haemorrhage - how do we get them safely around the hospital? LINKS https://soap.org/education/provider-education/expert-summaries/interim-considerations-for-obstetric-anesthesia-care-related-to-covid19/ https://www.oaa-anaes.ac.uk/OAA_COVID19_Resources

(*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 now. He states that they have seen their GP multiple times and have "tried almost everything". This is the second time they are presenting to your ED - they came 2 weeks ago where he recounts she was given some IV fluids and antiemetics before going home - but they were reluctant to come back because a member of staff was quite dismissive to them last time apparently she told them that if she ate ginger and sipped water she should be fine and "it all stops at 15 weeks anyway so not to worry it will be over soon". This time he tells you that she has practically eaten nothing in the last 4 weeks and she is now having trouble getting out of bed, because of almost 4 weeks of continuous vomiting. He thinks she has probably lost at least 8-10kg since becoming pregnant. He is "super-worried" and "she is just not herself anymore - please do something". She appears listless, drowsy and distracted when you try to question her directly, and she tells you she is thirsty, nauseated and has had enough - she even asks you as you take some bloods and place an iv whether it is permissible to get a termination for untreatable nausea. Bloods: pH 7.58 HCO3 28, PCO2 56, Na 126, K2.3, Gluc 8, LFTs normal Urinary Ketones +++, no glucose How would you approach the management of this woman? Join Graeme and I as we discuss this under appreciated & poorly understood yet potentially catastrophic condition...... USEFUL TREATMENT GUIDELINE https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf LINKS Profound Hypokalaemia Resulting in Maternal Cardiac Arrest: A Catastrophic Complication of Hyperemesis Gravidarum? Wernicke's encephalopathy in hyperemesis gravidarum: A systematic review. http://www.hyperemesis.org/ Pregnancy sickness can kill – why are doctors so uninformed about it? Why are Women Still Dying from Nausea and Vomiting of Pregnancy? http://theconversation.com/when-nausea-from-pregnancy-is-life-threatening-46709

(* Hypothetical Case) You are asked to see a pleasant 31 yr old woman in the antenatal clinic who is pregnant for the first time because as an adolescent she had an extensive scoliosis repair and now has Harrington Rods in her lumbar and thoracic spine. She tells you that she "is worried about being in a lot of pain during labour" and she wants to know what her options are. Hi everyone, This week three of us sat around our new AV equipment (thanks Trilby) to discuss the interesting and somewhat controversial topic of remifentanil PCA use for analgesia in labour. We discuss the history, the concerns regarding safety especially respiratory depression or apnoea, efficacy and some of the new evidence recently published. Links The RESPITE study in Lancet 2018 : Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial IJOA August 2019 Serious adverse events attributed to remifentanil patient-controlled analgesia during labour in The Netherlands IJOA August 2019 Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010–2015) BMC Pregnancy and Childbirth 2013 Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a “poor man’s epidural”

Hi Everyone, This week I am joined by Prof Mike Paech, Mike has dedicated most of his career to both the research and practice of obstetric anaesthesia. Join us in this podcast where we sat down to discuss the myriad of changes he has witnessed in Obstetric Anaesthesia over his career. We have now started an interactive poll where you the listeners can make suggestions to us about topics you would like to hear discussed! At this stage we are not making any guarantees but if there are certain topics that seem to be very popular and if we can find someone who feels empowered enough to talk on the topic we will see if we can make it happen! (If you can also supply someone to talk - even better - send us a separate email). Go to the home screen and scroll down to find the poll - see link below: https://www.obsgynaecritcare.org/

Hi everyone, Welcome back to part 2 of our discussion on the use of abbreviations and acronyms in healthcare. We discuss the results, go through some of the more obscure ones and then have a bit of a serious discussion about the advantages but also the dangers inherent in using these for communication in healthcare. Below are the correct answers and some "interesting" responses from the Ob / Gyn abbreviation quiz which Sneha compiled using some of the abbreviations found here in our women's hospital. If you want to have a go first - look away - and navigate back to the preceding post 060. Correct Answers "Interesting Answers" Do you have any interesting abbreviations or acronyms? Send them in!

"Where the f**k is the anaesthetist! I asked for the epidural 45min ago, those obstetric doctors took five goes to put in my drip, the midwife has turned up the hormone drip and now I am going crazy! Aaarghhhh!" Seem familiar? Hi everyone, Welcome back this week I am joined by long time listener and first time interviewee - Dr Sneha Neppali who sits down with me to discuss a couple of projects she has recently completed - epidural analgesia response times and the use of abbreviations in healthcare - specifically obs / gynae ones used during her recent time here at our women's hospital. How many of these abbreviations do you know? Want to see how Sneha faired on her recent TV appearances follow the links below: The Chase  https://www.youtube.com/watch?v=tEG7JZUTgyk&feature=youtu.be&fbclid=IwAR1DGM7uQtduFBX3kxL-DLJq4GPUf5wXV2NvmWa7m7l_4dq5HwIekNXE63A Millionaire Hot Seat https://www.youtube.com/watch?v=DcVJyd5j_9A&feature=youtu.be&fbclid=IwAR3amg4KC2CmAggv2foCplyzjXWnrwbxIODNS72VXPKZMeUevRRddDEoam0

Hi everyone, Once again I am joined by Graeme where we discuss an interesting obstetric case of Takotsubo cardiomyopathy that we were involved with and then do a deep dive into this fascinating condition! We are not cardiologists or experts in this condition by any means and all of our statistics and facts that we quote come directly from the recent 2018 international consensus documents from the European Heart Journal which I have referenced below. Finally we don't get a lot of feedback here on the podcast :(, if anyone knows any good jokes or has suggestions for future topics they would like us to explore please let us know! References 1 - International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. 2 - International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management

Hi Everyone, This week I am joined again by Nolan who was involved in writing the recently published international consensus guidelines on the use of uterotonic drugs at caesarean section. We discuss the pharmacology and mechanisms of all the different drugs used in clinical practice.  From a practical point of view these guidelines differentiate between oxytocin naive women, those who have been exposed to oxytocin (in labour) and those practitioners working in less well resourced settings. A big thank you to Trilby for helping to setup the new audio equipment! Hopefully the quality of these podcasts will start to improve over the next few episodes as we get to grips with how to use all this new stuff! Link International consensus statement on the use of uterotonic agents during caesarean section. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14757

  Hi Everyone, This week is part two of a series where Dr Mark Johnson and I discuss the emerging field of onco-anaesthesia. An increasingly enormous number of people every year undergo anaesthesia in order to have cancer surgery. Many different aspects of their surgical, anaesthetic and post surgical analgesic care are known to have effects on the immune system, the inflammatory response to surgery and some drugs act directly on receptors on cancer cells themselves. Is it possible or even probable that there are aspects of the techniques and drugs we use that could effect our patients long term cancer outcomes? Links How Anesthetic, Analgesic and Other Non-Surgical Techniques During Cancer Surgery Might Affect Postoperative Oncologic Outcomes: A Summary of Current State of Evidence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676329/ Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review https://youtu.be/Qj_MifzPGzo

Hi Everyone, This week I am joined by Dr Mark Johnson for part 1 of a two part series where we discuss the emerging field of onco-anaesthesia. An increasingly enormous number of people every year undergo anaesthesia in order to have cancer surgery. Many different aspects of their surgical, anaesthetic and post surgical analgesic care are known to have effects on the immune system, the inflammatory response to surgery and some drugs act directly on receptors on cancer cells themselves. Is it possible or even probable that there are aspects of the techniques and drugs we use that could effect our patients long term cancer outcomes? Links How Anesthetic, Analgesic and Other Non-Surgical Techniques During Cancer Surgery Might Affect Postoperative Oncologic Outcomes: A Summary of Current State of Evidence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676329/ Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563034/ https://youtu.be/Qj_MifzPGzo

Hi Everyone, This week we are joined by a colleague Dr Adam Mossenson. Adam sits down and over a cup of coffee we discuss his recent fellowship year spent overseas at Dalhousie University in Nova Scotia, where he was involved in designing and implementing a new anaesthesia simulation training course in Rwanda. This has now been so successful it is now being expanded to other locations around the globe. If anyone has any old (or new) ipads to donate to the program you can contact Adam through the VAST website below: Links https://vastcourse.org Adam also recently gave a talk to our local Anaesthesia Dept for those who would like to watch that: https://youtu.be/oABIjqLN8AE  

You are the duty anaesthetist and you receive a phone call from a midwife on the postnatal ward asking if you can come and review a woman who gave birth yesterday. She is 29 years old, with a BMI of 39 and gestational diabetes. She had an epidural placed in labour ward for analgesia - which she describes as being a difficult and unpleasant procedure. Following a prolonged and difficult labour she was taken to theatre and required an instrumental delivery in theatre under epidural - this too was difficult and she was in the lithotomy position for well over an hour for both the delivery and then the subsequent perineal repair. Today she is complaining of a "numb left leg". She and the midwife are concerned she has a nerve injury from the epidural. What should be your approach to this difficult situation? Hi everyone, Join Graeme and I for the second part in our series on complications of central neuraxial blockade and postpartum neurological injuries. We will discuss the specific issue of neurological problems - with the take home point being that in fact the underlying cause of the majority of these are related to the process of childbirth and not a direct injury from the epidural / spinal itself. There are however a few rare serious neurological conditions that need rapid diagnosis and treatment in order to avoid what could lead to catastrophic irreversible neurological injury. REFERENCES Neurologic Deficits and Labor Analgesia Cynthia A Wong M.D. Regional Anesthesia and Pain Medicine Vol 29, 4, 2004: pp341-351

You are the anaesthetist allocated to the anaesthetic outpatient clinic and you are asked to see a pregnant patient who is expecting her second child in a few months time who has been referred by a midwife from the antenatal services. She tells you that she had her first child three years earlier and that it was a very difficult and unpleasant experience. After a long difficult labour she asked for an epidural for pain relief. She describes that it was a very painful experience being placed and then it didn't work properly and despite being numb in her left leg she was still in a lot of pain. She then went to theatre for an emergency instrumental delivery - the anaesthetist there replaced it with "a new epidural" and she says she almost passed out and had trouble feeling her hands and breathing for about 30min. After delivery she had a numb patch on her left thigh and some musculoskeletal back pain for 6 months which she says a number of people have told her "were probably due to the epidural". She is very anxious about what will happen this time - she wants good pain relief during the labour because she had a lot of difficulty coping with the labour pain last time but is very worried about having another "epidural". She has also been told her baby is bigger this time and she might need to have a caesarean. She wants you to give her a detailed explanation of the known risks / complications of epidural analgesia and or anaesthesia should she need a caesarean. What are these and how will you explain these to her without making her anxiety even worse! Hi everyone, This week Graeme and I are back to discuss the known complications of central neuraxial blockade - or spinals and epidurals - in obstetrics. This week we will discuss all the known problems and complications that can occur - how to explain so the average lay person can understand them and doing it without scaring them to death! We refer heavily to NAP3 the great national audit project conducting in the UK and published in 2009 which highlights the overall safety of central neuraxial blockade and luckily how rare devastating neurological complications are. Next episode we will focus more specifically on the neurological injuries & deficits following childbirth and the specific causes (most of which are unrelated to the epidural or spinal!). REFERENCES National Audit of Major Complications of Central Neuraxial Block in the United Kingdom Report and Findings, January 2009

Hi everyone, This week Parvesh and I catch up to discuss some more serious issues - fatigue and burnout. Join us as we discuss these issues, share some anecdotes and even muse about the correct management of snake bites in pregnancy! Useful Articles https://academic.oup.com/bjaed/article/17/10/334/3865410 http://www.uapd.com/wp-content/uploads/Maslach-Burnout-Inventory-MBI.pdf https://academic.oup.com/bjaed/article/14/1/18/336242 https://anaesthetists.org/Fatigue Useful Resources a checklist that is also used in aviation that has been adapted to anaesthesia: https://anaesthetists.org/Portals/0/PDFs/Wellbeing/Fatigue/Fatigue%20Resources%20I'm%20safe.pdf?ver=2019-06-03-125010-637 fatigue tool useful at handover: https://anaesthetists.org/Portals/0/PDFs/Wellbeing/Fatigue/Fatigue%20Resources%20fatigue%20tool.pdf?ver=2019-06-03-125055-170  

Hi Everyone, This week I am joined by one of our provisional fellows and we discuss the serious topic of bullying in healthcare and anaesthesia. Unfortunately this sort of behaviour is more common than we appreciate...... Take home messages from Peter's talk • This does happen to us • It is not something that should be ignored • I think good change is happening Want to listen to Peter's department talk as well? Follow the link to our presentation page: https://www.obsgynaecritcare.org/education-presentations/ Links https://www.beyondblue.org.au/ http://www.anzca.edu.au/documents/anzca-policy-on-bullying-discrimination-and-harass.pdf

Hi everyone, Recently Graeme and I were asked to help run a workshop here in WA for the ANZCA Emergency Response CPD programme - thanks for your help Graeme and Paras. Some of the key concepts were understanding blood products and the strategies / philosophies which have been used when deciding what to give in a major haemorrhage. We decided that this would make a great podcast discussion and so voila - here it is! We discuss: - massive transfusion protocols utilising empiric ratios of blood products (often heavy in FFP / plasma) versus the more targeted approach often based on rapid assessment of haemostasis using viscoelastic tests such as ROTEM / TEG. - the four deficits in haemostasis which can develop; 1 fibrinolysis, 2 fibrinogen deficiency, 3 platelet deficiency, 4 thrombin deficiency. -a description of the types of blood products available their pros / cons. - why the use of large volumes of plasma probably doesn't make sense and may in fact involve some harm to patients. - an alternative strategy for empiric therapy when rapid tests of coagulation are not available empiric treatment with tranexamic acid and fibrinogen. Thanks for another great dicsussion Graeme! USEFUL LINKS https://www.obsgynaecritcare.org/rotem/ https://www.obsgynaecritcare.org/rotem-real-cases-discussed/ LINKS Study showing decreased massive transfusion rate in trauma after change to goal directed ROTEM therapy in Switzerland.Anaesthesia. 2017 Nov;72(11):1317-1326. doi: 10.1111/anae.13920. Epub 2017 May 23. Change of transfusion and treatment paradigm in major trauma patients.Before and after the introduction of ROTEM guided fibrinogen concentrate at Liverpool Womens Hospital and improved outcomes. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2015 Feb;70(2):166-75. doi: 10.1111/anae.12859. Epub 2014 Oct 7

Hi Everyone, This week we have a great four person discussion around the importance of assembling the right team when confronted with a high risk complex case in the after hours period. Interesting points covered include still doing the team huddle and introducing everyone even at midnight, a detailed discussion around manual aortic compression - the IVC, and how to monitor effectiveness - and also using a posterior hysterotomy to deliver the fetus when everywhere else looks bad! Thanks to IKEA for their contribution to our high tech podcast studio! Thanks also Parvesh, Matt Epee-Bekima & Matt Rucklidge for this great discussion. (* The patient discussed in this podcast gave us explicit written consent for her case to be used in this deidentified discussion) High Tech Podcasting Studio (Thanks IKEA for your plastic bin!) Links https://www.obsgynaecritcare.org/017-prof-yee-leung-obstetric-and-surgical-management-of-abnormally-invasive-placenta/ https://www.obsgynaecritcare.org/015-placenta-percreta-perioperative-and-anaesthetic-management/ https://www.obsgynaecritcare.org/041-obstetric-cell-salvage-an-update-what-only-one-suction-no-filter-and-more-with-dr-matt-rucklidge/ https://www.obsgynaecritcare.org/manual-aortic-compression-life-saving-in-massive-obstetric-haemorrhage/ https://www.youtube.com/watch?v=rc9BYcIhamA

Hi Everyone, This week I had the privilege to sit down and chat with Dr Casey Parker (or is that Paraka? - apologies a little inside joke ). Casey works up in Broome as a GP anaesthetist, in emergency medicine, the HDU, is an enthusiast for point of care ultrasound and is involved in FOAMed and a huge number of other educational initiatives. Casey has had his own very successful website / podcast / blog (www.broomedocs.com) for over 7 years and he was one of the original people who encouraged me a few years ago. This week I sat down and quizzed him about his own journey in the FOAMed world, what he has learnt along the way, what his favourite podcasts are and if he has any advice for people out there who are also interested in getting involved. Thanks for sitting down and sharing your wisdom Casey! FOAMed Blogs / podcasts mentioned in our discussion https://emcrit.org/ http://accrac.com/ www.topmedtalk.com Home Other Links https://www.nosuchthingasafish.com/ www.hamishandandy.com

(*Hypothetical patient) You are called to review a woman who recently arrived in your hospital and is now a few hours postpartum after a pre-term vaginal delivery at 35 weeks. She tells you that she has felt unwell for the last few days with a little bit of vomiting, diarrhoea and her asthma has been playing up and needing quite a few puffs of her ventolin. She went into preterm labour and delivered quickly 2-3 hours ago. She has received 3-4 litres of crystalloid to treat her "dehydration" and the at times non reassuring CTG over the last 24hours. She isn't febrile, but is tachycardic at 115/min, hypotensive 95/45 and she looks a little short of breath with Sp02 92% on room air and a respiratory rate of 20/min. She can talk in sentences and is walking around her room so you are reassured by this. After taking a history and examining her you decide to have a quick look at her heart and lungs with your USS machine (you have recently completed a point of care ultrasound course so are always looking for an opportunity to put your new skills into practice). To your surprise you discover the apices of both her lungs have a large number of B-lines and then when you throw the probe on her heart and inferior vena cava within a couple of minutes you see she has a large poorly contracting left ventricle and a dilated IVC. You reach over and turn off her iv fluids - this woman doesn't need anymore rehydration! Hi everyone, This week Parvesh and I follow up on our earlier podcast discussing the utility of point of care lung ultrasound with a discussion about the merits of point of care echocardiography. Join us and as we discuss the pros / cons, share some anecdotes and talk about where we are on our journey learning this incredibly useful new technique. B-Lines on Pulmonary Ultrasound = interstitial fluid Mitral Stenosis Links https://www.obsgynaecritcare.org/lung-ultrasound-a-discussion-with-dr-parvesh-verma/ 1. Focused transthoracic echocardiography in obstetrics. Griffiths, S.E. et al. BJA Education , Volume 18 , Issue 9 , 271 - 276 2. Transthoracic echocardiography in the perioperative setting. Jørgensen, Martin Ruben Skoua; Juhl-Olsen, Petera; Frederiksen, Christian Alcarazb; Sloth, Erika Current Opinion in Anaesthesiology: February 2016 - Volume 29 - Issue 1 - p 46–54 These articles are not free open access - they are available through most university / hospital libraries or your medical college (eg ANZCA).

Scenario: You are called by a midwife to review a patient on the ward who had a vaginal delivery yesterday with an epidural for pain relief and now she has a bad headache. They are concerned that maybe she has a postdural puncture headache. Join Matt and Roger again as this week they discuss the management of a patient with possible or proven post-dural puncture headache. Links "What I wish I knew about post-dural puncture headaches before I got an epidural" Todays Parent Postpartum headache: diagnosis and management BJA Education 2011 Free article https://www.obsgynaecritcare.org/016-sphenopalatine-ganglion-block-for-postdural-puncture-headache/

You are called down to labour ward to put an epidural into a woman who is extremely distressed, in the throes of established labour who is thrashing around the bed in agony. You introduce yourself and she looks up at you and says "you ain't gonna give me a terrible f**** headache like that a******* who did ma epidural three years ago are ya?" This week we are joined again but Dr Matt Rucklidge for a discussion on what is arguably still the most common serious problem which continues to plague obstetric anaesthetists. Ever since August Bier and his trusty assistant Hildebrandt inflicted this condition on eachother in the late 1800s when experimenting on themselves at the very birth of spinal anaesthesia we continue to struggle with this important and pressing problem. August Bier - Father of spinal anaesthesia. He also personally experienced a 9 day postdural puncture headache! Interesting Links "What I wish I knew about post-dural puncture headaches before I got an epidural" Todays Parent The Centennial of Spinal Anesthesia 

You are called down to your HDU to review a 81 year old woman who is day one following a major laparotomy for ovarian cancer surgery. The nursing staff are worried because "she is not quite right". She hasn't made much urine over the last 3 hours, her blood pressure is a little low and she has also developed low peripheral oxygen saturations on room air and is now needing 3l/min via nasal prongs. She had a unit of blood earlier this morning and has had 4-5 litres of intravenous fluid now both during and after her operation. What to do? Should you give her a 500ml bolus of fluid to help her urine output and maybe boost her BP a little? But why are her saturations low - what if you push her into florid pulmonary oedema? Why are her sats low? Does she have pleural effusions? atelectasis? early pulmonary oedema? Should you give her a vasopressor? some frusemide? some physio? some more fluids? Aaarrgggh! You get out your stethoscope - her lungs are quiet at the bases and she is slightly breathless but you are still not sure what's going on. You move your stethoscope to teh middle of her chest and you can't hear any murmurs - but this doesn't really tell you that there is nothing wrong with her heart or valves for that matter!. Oh well at least you had a couple of quiet minutes without talking to the patient or nurse to think about what you might do next ! Only 10m away in the corner of the unit you spot the portable USS machine, which has a curvilinear and phased array probe. You remember the talk from your colleague last week on point of care USS. They described how in around 5min you could probably confidently answer most of these questions & you make a mental note that you are definitely going to sign up for that course in 2 months time... Hi Everyone, Welcome to this weeks podcast episode where Dr Parvesh Verma and I discuss the pros and cons of lung ultrasound and the vastly under utilised potential of this relatively easy to perform bedside technique. Lung ultrasound is relatively easy to learn, is vastly more accurate than lung auscultation, quite a bit better than CXR and as good as invasive radiation heavy investigations like chest CT. In just about every clinical setting we all have access to an ultrasound machine now. If you ever listen to someone's chest or look after patients with dyspnoea (in hospital or a clinic ) then hopefully this episode will inspire you to go away and learn this incredibly useful skill! Merry Xmas & Happy New Year!  This will probably be the last episode this month - I am keen to get suggestions on topics for future episodes so please send me all your suggestions and great ideas! References / Links There are a huge number of free resources out there to introduce you to this topic - please search for them yourself. The links below are not necessarily the best but you might find them useful: Practical Guide to Lung Ultrasound BJA Education - free article  Lung ultrasound compared with chest X‐ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study† BMJ - Lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. Fact or fiction? Youtube Tutorial A short video tutorial is one of the best ways to introduce yourself to the basics of lung ultrasound. Therea re a large number of video tutorials on this topic - choose your own favourite! Here are a couple which I thought were good: https://youtu.be/jh7EP7jiW98 https://youtu.be/e_wloEfvs1M

Hi everyone! Better late than never. This week Chong and I have finally got around to our discussion on anaphylaxis. What are the common causes of anaphylaxis? How is the severity of anaphylaxis graded? How / when should we administer adrenaline and what are the pitfalls of this drug which has a  narrow therapeutic window? We focus mainly on discussing the common causes in hospital and particularly the peri-operative setting. Peri-operative anaphylaxis is now the leading cause of direct anaesthetic related death in Australia / NZ. We do offer a few quick thoughts on the common causes and management of anaphylaxis in the community (how many of you have been asked to help manage these reactions for example on a plane at a school or community event - where invariably someone says get so and so they're a doctor / nurse!). If you haven't I suspect it will only be a matter of time before someone ingests a peanut on a flight you're on! Do you know how to use an epi-pen? They are pretty straight forward but nice to know what to do without having to read the instructions on the device mid flight when it's handed to you by a flight attendant! A big shout out to the ANZAAG special interest group at ANZCA who have put together an amazing online learning package and who are the true experts in the area of peri-operative anaphylaxis management. I strongly recommend those listeners who are members of the anaesthesia community log onto to the ANZCA networks website and complete this online learning package which also satisfies the CPD emergency response requirement for members of the ANZCA college. Links NAP6 - UK national audit project on perioperative anaphylaxis examining over 3 million anaesthetics. ANZAAG - Australia and NZ Anaesthetic Allergy Testing Group Online Courses: For members of ANZCA: We highly recommend that you complete this perioperative anaphylaxis online course  available through the ANZCA Networks site: https://networks.anzca.edu.au Health Professionals in general: ASCIA health professional anaphylaxis e-learning course:   https://etraininghp.ascia.org.au/ Members of the general public: ASCIA community anaphylaxis e-training  https://www.allergy.org.au/patients/anaphylaxis-e-training-first-aid-community YOUTUBE How to use an Epipen properly ! - fast forward to 3:30 to see the injection technique. https://youtu.be/YheJhyQ168Y    

Hi everyone, Anaphylaxis is an unpredictable scary life-threatening condition which unfortunately is more common than we would like. If you work in healthcare chances are you will have seen this condition or perhaps you may even be unlucky enough to have suffered an anaphylaxis yourself. To introduce the topic in this first episode, Graeme and I discuss a life threatening case of perioperative anaphylaxis to intravenous muscle relaxant, which occurred a few years ago. This case was pretty stressful and about as severe as it can get but it demonstrates a number of important aspects of this potentially life-threatening condition. (* The patient involved in this case provided written consent for the details to be used for education - some aspects of this case have also been published in a case report in the International Journal of Obstetric Anaesthesia). Next week we have a detailed discussion including the pathophysiology, talk about the NAP6 national audit into perioperative anaphylaxis in the UK, and of course discuss the management principles and finally offer you some links to important useful education resources. References NAP6 UK National Audit Project into perioperative anaphylaxis (* The patient involved in this weeks case provided written consent for her case to be used for education - some aspects of this case have also been published in a case report in the International Journal of Obstetric Anaesthesia). Here is the published case report of the case we discussed in this podcast - focusing on the hyperfibrinolysis which occurred: H.T.Truong, R.M.Browning Anaphylaxis-induced hyperfibrinolysis in pregnancy. International Journal of Obstetric Anesthesia; Volume 24, Issue 2, May 2015, 180-184

Hi everyone, Welcome to part 2 of our series on cell salvage in obstetrics and gynaecology! Last week we had a great discussion on the basics of cell salvage and focused on what the team in the surgical field need to know to do a great job. If you haven't listened to that yet check it out here: Link This week we welcome back Dr Matt Rucklidge and we have the recording of the talk he gave our department recently on the latest thoughts surrounding the use of cell salvage in obstetrics. If you haven't been watching this space closely over the last few years you may be unaware that there has been a definite change in approach to many aspects of how obstetric cell salvage is now done. Listen to Matt present a very balanced and thoughtful discussion on the following: it's ok to be collecting amniotic fluid during cell salvage the use of only one suction is now routine in many centres a softening in the stance on the need for use of leukodepletion filters when reinfusing salvaged obstetric blood. Some of his talk is based on the following recent articles: RECENT ARTICLES LATEST VERSION JULY 2018 UK GUIDANCE ON CELL SALVAGE -This is open access and free (hooray!) https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14331 SALVO STUDY  - fulltext (also open access hooray!) :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5736174/ VIDEO VERSION OF THIS TALK https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0 WHAT ABOUT VAGINAL CELL SALVAGE? Cell salvage for postpartum haemorrhage during vaginal delivery: a case series. Blood Transfus 2017 Is cell salvaged vaginal blood loss suitable for re-infusion? IJOA 2015 ONLINE EDUCATION RESOURCES National Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/ics Great resource from the UK pdfs and free slides on all the various aspects of cell salvage: https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education WHY SHOULD WE USE CELL SALVAGE? If you want to revise the benefits of autologous blood (i.e. the patient's own blood) then listen to this earlier episode:  

Hi Everyone, Welcome to part 1 of a two part series on the use of cell salvage in obstetrics & gynaecology! This week Part 1 focuses on the basics of how cell salvage works and what the staff in the surgical field (nursing and surgical) need to know to do it properly! Next week we hear from Dr Matt Rucklidge who discusses all the latest controversies and developments in the arena of cell salvage during obstetrics - can we use a single suction, what about amniotic fluid in the collection system, do we always need a leukodepletion filter and how can we organise our practice so that we utilise cell salvage during those unexpected emergency cases? These two episodes are audio extracts taken from a great combined presentation given at our local department meeting here in August. The audio from these presentations are great but for those of you who are interested in viewing a video version of this talk where you can also see the slides and images referred to in the talk feel free to watch using the link below: VIDEO VERSION OF THIS TALK https://www.dropbox.com/s/x19ximgn0d814rn/Cell%20Salvage%20update%20August%202018.mp4?dl=0 ONLINE EDUCATION RESOURCES National Blood Authority guidelines for intraoperative cell salvage: https://www.blood.gov.au/ics Great resource from the UK pdfs and free slides on all the various aspects of cell salvage: https://www.transfusionguidelines.org/transfusion-practice/uk-cell-salvage-action-group/intraoperative-cell-salvage-education WHY SHOULD WE USE CELL SALVAGE? If you want to revise the benefits of autologous blood (i.e. the patient's own blood) then listen to this earlier episode: https://www.obsgynaecritcare.org/022-stored-blood-versus-fresh-salvaged-blood/

Case scenario: Mrs A Nonymous is a 67 yr old woman with a diagnosis of probable ovarian cancer who is booked for a midline laparotomy and debulking cancer surgery. She is a smoker, has a BMI of 50 and weighs 115kg. She was diagnosed with OSA 5 years ago but doesn't use CPAP because she couldn't tolerate it. She has had longstanding back pain for many years which she blames on an epidural which she had during childbirth 30 years ago. She has had 2 previous back operations "which didn't help" and now takes 3 analgesics for this pain which include moderately high dose oxycodone, pregabalin, and tramadol. She tells you that she definitely will not consent to any spinal or epidural because of all of her previous back issues... She is opioid tolerant and at high risk of serious opioid related respiratory adverse effects - how are you going to manage her pain, get her mobilising and avoid any technique that involves a needle in the back! Hi everyone, This week we have an interview with Dr Matt Rucklidge, a colleague and good friend who is also a consultant anaesthetist practicing here in Western Australia. Matt trained in the UK and worked in southern England, one of the pioneering regions, where he first became acquainted with the use of rectus sheath catheters for postoperative analgesia after midline laparotomy. He has helped us successfully introduce this very effective technique into our institution where it has now become the default analgesic technique for the majority of our patients undergoing major intra-abdominal surgery with a midline incision. BJA EDUCATION Article https://bjaed.org/article/S2058-5349(18)30033-7/abstract Unfortunately contrary to my comments on the podcast - this article does not appear to be open access and when I tried to access it today it requires an institutional subscription or an individual payment. If you are an employee of a health service / university or a member of a college you may be able to access the article through these channels. Want to know more about the open access debate? See our previous podcast on this here: https://www.obsgynaecritcare.org/036-sci-hub-earthquakes-listener-mail-pirate-jokes-and-another-quiz/ Instructional Videos https://youtu.be/Xq-H3SLLwO0   https://youtu.be/_r_pVQf4C5w

Hi Everyone! This week I am joined on the podcast by Dr Katrina Calvert a senior trainee in Obstetrics and Gynaecology here in WA.  Katrina has a long career spanning both sides of the globe in medical education and has a real passion for the use of simulation in O&G. We discuss all things simulation: what makes good simulation? do you need expensive hi-fidelity equipment? what does the future hold? what are the barriers to the use of simulation and how can we overcome them? we also share some interesting anecdotes of participants who have perhaps become a little "too immersed" in their particular scenario! Thanks Katrina for a very enlightening discussion - we look forward to getting you back on the podcast soon! Links To Courses in Australia Maternity Emergency Management:  Simulation day for obs emergencies NOVICE – basic skills in O&G for RMO’s PHO’s https://www.matereducation.qld.edu.au/Professional-development-learning/Maternity-Infant-Care For those interested in developing their sim educator skills, most sim centres offer a basic course, as we do.  For those with some skills already, we also regularly host the Harvard team for the “simulation as a teaching tool”, and “advanced debriefing” courses. https://www.matereducation.qld.edu.au/Professional-development-learning/Simulation-Faculty-Development http://www.promptmaternity.org/au/ http://moetaustralia.com/ https://www.amare.org.au/advanced-life-support-in-obstetrics-also/

(Real Case: De-identified) You receive a call from a frantic ward nurse who tells you they have a 32 yr old woman who had laparoscopic surgery for treatment of endometriosis earlier in the day and she is in severe pain despite having had 3 doses of sublingual buprenorphine and 4 doses of tramadol since theatre 4 hours earlier. You head up to the ward and read her notes - she has had chronic pelvic pain since a teenager, she has been on analgesic drugs chronically for many years and been managed by her GP and a chronic pain service. She has a history of anxiety and depression and sexual abuse as an adolescent. Her current preoperative regimen involved tapentadol SR, amitriptyline, celebrex, pregabalin and prn oxycodone. In theatre she had a volatiel anaesthetic and a number of multi-modal analgesic medications including a small dose of methadone, ketamine, lignocaine. She needed a lot of fentanyl in recovery and since arrival on the ward has been very hard to control. You go and see her, she is definitely not narcosed from all these drugs! She is wide awake, slightly tachycardic (HR 105), restless and complaining of diffuse abdominal pain. She says "Doc it's 11/10" and is asking for you to give her something else to help please! You talk her about your options then decide together to admit her to your HDU for overnight intravenous lidocaine infusion. She has the 100mg loading dose over 10min then is started on a 1mg/kg/hr infusion. Within 2 hours she is asleep and when you see her in the morning she says her pain is only 3/10 and she thanks you profusely.... Hi this week on the podcast we are joined by my colleague Dr Kevin Chan and we discuss the pros / cons of intravenous lidocaine infusions and it's increasing use in perioperative pain management! Previous Podcasts The Opioid Epidemic a discussion with Dr Sonia Ting References Intravenous lidocaine for acute pain: an evidence-based clinical update. BJA Education, Volume 16, Issue 9, 1 September 2016, Pages 292–298. Free Article Podcast with author from the above article: Their experience at Ottawa Hospital Lidocaine Infusions: The golden ticket in postoperative recovery? Australasian Anaesthesia 2017 p 185-196 (e.g. Blue Book article). Perioperative Use of Intravenous Lidocaine. Lauren K. Dunn, M.D., Ph.D.; Marcel E. Durieux, M.D., Ph.D. Anesthesiology 4 2017, Vol.126, 729-737.

Want to put together a tutorial? See someone with an unusual condition in clinic and want to access some up to date knowledge to look after them? The first thing most of us do is search the current literature - but then often we face this - look familiar? What is Sci Hub? If you're lucky you are an employee of a hospital / university or college that has a subscription and you can usually gain access eventually through these channels. But what if the journal is not included in their bundle or spare a thought for our colleagues living in less affluent conditions - how will they access up to date knowledge and research?? Join Graeme and I this week as we discuss earthquake stories, Sci-hub, open access publishing, pirate jokes, respond to some listener mail and I try out another quiz! This Weeks Quiz Who is this famous person? - I am an obstetrician! Sci-Hub Open Access Related Links Wikipedia Sci-hub page Online Petition against Elseviers fees > 17200 academics  Wikipedia academic publishing page German universities cancel subscriptions to all elsevier journals and push for open access: Projekt DEAL Podcast on the history of scientific publishing interview with Aileen Fyfe Earthquake Related Links 1995_Gulf_of_Aqaba_earthquake 2018 WAAG Conference    

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 helped author a recent article in the famous ANZCA blue book (see the link below): Unfortunately patients with surgical airways and tracheostomies are not confined to just the ENT wards - they all often have associated comorbidities and medical problems which mean they can be encountered anywhere in the hospital or healthcare settings. Whether we like it or not we could all get called to deal with an emergency - and so we all need to have some basic understanding of tracheostomies and skills in dealing with any crises or problems which could occur! In this episode we discuss the perioperative management and emergency management of these airways. If anyone is keen to attend the FSH tracheostomy crisis management course, James is happy for you to contact him via email at james.anderson@health.wa.gov.au Tracheostomy.org.uk emergency management crisis card: USEFUL LINKS http://tracheostomy.org.uk/ ANZCA Blue Book 2017 - http://www.anzca.edu.au/documents/australasian-anaesthesia-2017.pdf https://constitutioncenter.org/blog/the-mysterious-death-of-george-washington

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 following person an anaesthetist or is he a serial killer (or perhaps is he both!) Massive bonus points available if you can actually name this individual!

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 pregnancy, childbirth and anaesthesia / analgesia? This week I am joined by my colleague Chong to discuss this interesting but very challenging condition. Neither Chong or I consider ourselves to be experts in this condition but we have both come across patients with the Fontan circulation during our careers & we are well aware that we may be expected to look after someone with this condition again!! Please listen to the podcast - we have tried to distil out the important issues and explain them in a sensible manner. If you notice any errors or disagree with any of our content please let us know in a comment! Conditions usually palliated with a Fontan Repair Dr Francis Fontan Dr Fontan from Bordeaux, first described this palliative surgical procedure in 1971. He sadly passed away at the age of 89 earlier this year (Jan 2018). REFERENCES /ARTICLES The Australia and New Zealand Fontan Registry: description and initial results from the first population-based Fontan registry. Anaesthetic management of parturients with univentricular congenital heart disease and the Fontan operation.Int J Obstet Anesth. 2016 Dec;28:83-91.  USEFUL LINKS ANZ Fontan Registry - A great website! https://www.fontanregistry.com/ The different types of Fontan procedure: https://www.fontanregistry.com/the-different-fontan-procedures Khan Academy Youtube tutorial - Detailed description of the 3 stage surgical creation of a Fontan circulation in child with hypoplastic left heart syndrome: https://youtu.be/4GUm8ybncWY Layperson description of the Fontan Heart: https://www.youtube.com/watch?v=1bMq2eWfyyw  

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"? Is this just an issue for North America? How relevant is it to us here in Australia? As health care practitioners what has been our role in contributing to the development of this very serious crisis which is killing more young people than HIV / trauma / guns? This week I interview Dr Sonya Ting - a consultant in anaesthesia and pain medicine. We discuss the opioid epidemic, how it evolved and what we can do as healthcare practitioners. References New York Times article on Purdue pharmaceutical /  https://www.nytimes.com/2018/05/29/health/purdue-opioids-oxycontin.html ABS statistics on drug induced deaths  http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2016~Main%20Features~Drug%20Induced%20Deaths%20in%20Australia~6 US Department of Health and Human Services https://www.hhs.gov/opioids/about-the-epidemic/index.html Opioid Risk Tool https://www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf ANZCA / FPM Options for a Regulatory Response to Potential Misuse of Schedule 8 (S8) Opioids in Australia http://www.anzca.edu.au/documents/anzca-prescription-strong-(schedule-8)-opioid-use.pdf  https://www.sbs.com.au/news/prince-s-fatal-fentanyl-level-higher-than-any-previously-recorded-experts https://www.rollingstone.com/music/news/tom-pettys-cause-of-death-accidental-overdose-w515472 http://www.nme.com/news/film/philip-seymour-hoffman-mimi-odonnell-death-addiction-2171711 Other Great Podcast Episodes on this topic ACCRAC (anesthesia critical care reviews and commentary) -  This is a great podcast on all manner of perioperative / anesthesia and pain medicine topics by Assistant Professor Jed Wolpaw at John Hopkins in the US. Check out these two great interviews with pain specialists discussing it from a US perspective and practical advice on what we can do. http://accrac.com/category/pain/ Monash University Perioperative Medicine Podcasts Episode:The Opioid Epidemic - a Perioperative Perspective - Dr Kerry McLaughlinhttps://www.periopmedicine.org.au/index.php/podcast-home

(*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 break out in a cold sweat but the truth is this is a topic that everyone who uses local anaesthetics needs to be aware of. Indeed many of the reported cases of this life threatening complication have been local anaesthetics used by surgeons, dentists, and other health care practitioners. What is LAST? Local Anaesthetic Systemic Toxicity Local anaesthetics are amazing analgesic medications which have  many advantages over analgesics like opioids (we here at obsgynaecritcare are big fans of regional analgesia techniques). However in the wrong dose or route these medications block sodium channels in the heart and brain & can cause lethal CNS and cardiac toxicity. This week I interview Dr Chris McGrath one of our anaesthesia fellows. We discuss the updated ASRA guidelines for management of LAST. There are now some new considerations to traditional ALS and we detail the role of more specific therapies such as intralipid and ECMO. Links http://www.lipidrescue.org/      The definitive website on the use of intralipid to treat local anaesthetic toxicity (and other drug toxicities). There is a fascinating explanation of the discovery of intralipid therapy by Guy Weinberg (a US anesthesiology researcher), as well as many interesting cases and a great up to date review of the research on this therapy. https://www.asra.com/advisory-guidelines/article/3/checklist-for-treatment-of-local-anesthetic-systemic-toxicity     The ASRA (American Society of Regional Anaesthesia and Pain Medicine), checklist for the management of LAST  https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf    AAGBI (Association of Anaesthetists of Great Britain and Ireland) 2010 LA Toxicity guideline Bupivacaine 0.75% causing maternal deaths.    Read this report to the British Journal of Anaesthesia in 1986 describing the withdrawal of bupivacaine 0.75% for use in obstetrics by the FDA following up to 31 maternal deaths from LA toxicity in epidural anaesthesia in North America. References CHEER Trial.  Stub, D et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation 86. (2015) 88-94. ASRA Guidelines. Neal, J et al. The American Society of Regional Anaesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version. Regional Anesthesia and Pain Medicine. Vol 43(2) pg. 150-153 ASRA Case Series. Gitman, M et al. Local Anesthetic Systemic Toxicity: A Review of recent Case Reports and Registries. Regional Anesthesia and Pain Medicine. Vol 43(2) 124-130. AAGBI Guidelines. The Association of Anaesthetists of Great Britain and Ireland 2010. Cave, G et al. AAGBI Safety Guideline: Management of Severe Local Anaesthetic Toxicity. Available [On-Line]:https://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf Lasts Weeks Quiz! Congratulations to Sneha and Jeremy (a close second).

(*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 subclavian (SC) or Femoral. Surgical cut-down - saphenous or brachial. Graeme even discloses that he has trialled unsuccessful sternal intraosseous placement in the past - sounds like an interesting case we should perhaps delve into more detail on at another time!! Hagen-Pouseille Equation: Bottom line - shorter and wider bore catheters are better for rapid fluid resuscitation. The MAC line - note swan sheath, haemodialysis or other large bore central catheters will also work: Youtube / Podcasts Discussing this topic: https://theprocedurescourse.com/blog/ A great course to learn emergency procedures for use in trauma care run by the critical care trauma team at The Alfred in Melbourne. Check out their description of vascular access in particular their detailed description of the technique for emergent placement of the large bore MAC line in the subclavian vein. 2. https://emcrit.org/pulmcrit/hemodynamic-access-for-the-crashing-patient-the-dirty-double/ A great discussion on the placement of large bore femoral catheters. 3. The Rapid IJ - Ultrasound guided placement of a peripheral iv cannula in the internal jugular. https://youtu.be/FjSmbUWXznY References A novel "shrug technique" for totally implantable venous access devices via the external jugular vein: A consecutive series of 254 patients. Kagawa T, et al. J Surg Oncol. 2017 Mar;115(3):291-295. doi: 10.1002/jso.24504. Epub 2016 Nov 4. The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. J Trauma Acute Care Surg. 2018 Apr;84(4):558-563. Safety and Efficacy of the "Easy Internal Jugular (IJ)": An Approach to Difficult Intravenous Access. Moayedi S, et al. J Emerg Med. 2016 Dec;51(6):636-642. doi: 10.1016/j.jemermed.2016.07.001. Epub 2016 Sep 19. QUIZ 2 These are ABG's from four different individuals? What do these represent? First correct answer gets kudos and a mention on the next podcast!  

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 viscoelastic tests like ROTEM) are not rapidly available. However there are some exceptions to this rule - beware early onset of coagulopathy in women with abruption, HELLP, and AFE! Links Obstetric Intensive Care Symposium Adelaide 2018 https://www.picet.org.au/programme.php If you want to watch the video of this talk with it's powerpoint slides: https://www.dropbox.com/s/y57pf26ge9mry8g/Obstetric%20coagulopathy%20Nolan%20KEMH%20dept%20talk%20version.mp4?dl=0  

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. We hope you will find some of these tips useful if you ever have to care for these women. This is by no means a comprehensive list of tips and we would welcome any other suggestions for tips / techniques you have personally found useful - let us know in the comments below! Practical Tips (in no particular order) Blood pressure monitoring - cuffs on the upper arm often struggle to work - consider a standard adult cuff on the forearm or if in theatre put in an arterial line. Ultrasound is your friend to get good reliable intravenous access. Two iv's if in theatre as they tissue easily and you want to have a back up in case one stops working halfway through surgery! Be VERY CAREFUL with manual handling and positioning issues - use proper epidural positioning devices (not people, chairs or stools). Lots of people to carefully move them. Ultrasound is your friend when attempting a neuraxial block! Have the long tuohy and spinal handy. Consider tunnelling your labour ward epidural to prevent it falling out - if you have learnt this technique. Anticipate potential obstructive sleep apnoea & respiratory issues and be very careful with opioids and sedatives - use non sedating regional analgesia / NSAIDs etc. General anaesthesia - fraught with danger - beware airway, ventilation (& circulation issues)! - these are not patients you want to crash off to sleep in a hurry even if our obstetric colleagues are concerned about the foetus............Careful positioning (Oxford or Troop devices), apnoiec oxygenation during induction, videolaryngoscopy (e.g. CMAC) and the difficult airway trolley ready to go. Helpful Illustrations: Extra long Tuohy and spinal needles Large upper arm BP cuff - often doesn't work well. Use a standard adult BP cuff placed on the forearm Epidural positioning device - much safer than using a chair / stool or partners legs Ultrasound guided intravenous cannula placement - often there is a large vein in the mid forearm directly above the radius. References Tunnelling Epidural Catheters: An editorial discussing tunnelling of epidural catheters to prevent accidental catheter migration and Dr Pavy's famous 1994 article! Tunnelling epidural catheters: a worthwhile exercise? Editorial N. Kumar W. A. Chambers Anaesth Intensive Care. 1994 Dec;22(6):703-5.Tunnelled epidural catheters for routine use: description of a technique. Pavy TJ1. Management of supermorbidly obese parturient with two epidural technique: Anaesth Intensive Care. 2007 Dec;35(6):979-83.The management of a super morbidly obese parturient delivering twins by caesarean section.McDonnell NJ1, Paech MJ.  

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 weeks blood gas - taken from 23 day old stored allogeneic red cells References Click on these to link to the pubmed article: 1.  Osman N. Salaria, MD, Viachaslau M. Barodka. Impaired Red Blood Cell Deformability After Transfusion of Stored Allogeneic Blood but not Autologous Salvaged Blood in Cardiac Surgery Patients. Anesth Analg. 2014 Jun; 118(6): 1179–1187. 2. Andrew V. Scott, BS, Enika Nagababu. 2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion. Anesth Analg. 2016 Mar; 122(3): 616–623. 3. Xiu Liang Li,1 Peng Dong. Oxygen carrying capacity of salvaged blood in patients undergoing off-pump coronary artery bypass grafting surgery: a prospective observational study. J Cardiothorac Surg. 2015; 10: 126. 4. National Blood Authority video - blood still saving lives but there are risks.

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 good review please! To finish the podcast we have a quiz, a blood gas result which is posted below. I asked Graeme to read this out & briefly describe it to listeners - however he gets a little carried away and lets the cat out of the bag so I have had to censor him - I suspect this may not be the last time I have to do this.......   What does this blood gas show? Please send in your comments - the first to correctly guess will get a mention on the show next week! Sorry we don't have any T-shirts or mugs to give out so the glory of your name in print and on the show will have to do..... See you next week!

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 they'd like to share please leave us a comment we'd love hear from you! Roger References AMOSS, the Australasian Maternities Outcomes Surveillance System: https://www.amoss.com.au/ Society for Maternal-Fetal Medicine (SMFM) with the assistance of Pacheco LD, Saade G, et al. Amniotic fluid embolism:diagnosis and management. Am J Obstet Gynecol 2016;Aug;215(2):B16-24. McDonnell NJ, Percival V, Paech MJ.Amniotic fluid embolism: a leading cause of maternal death yet still a medical conundrum. Int J Obstet Anesth. 2013 Nov;22(4):329-36 Listen to last weeks fascinating case of AFE: 019 – Amniotic Fluid Embolism – a case discussion with Assoc Prof Nolan McDonnell  

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 parturient with amniotic fluid embolism. Int J Obstet Anesth. 2007 Jul;16(3):269-73 https://www.ncbi.nlm.nih.gov/pubmed/17337177  

(*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 next! What are you going to advise over the phone? What should have been done differently in the antenatal period? Join Graeme and I in this podcast. Thanks to Graeme for again being a good sport and agreeing to join in this podcast to make it more of a conversation and easier to listen to! He had to ad-lib, completely off the cuff, without any warning (I literally grabbed him in the corridor). - Tune in to find out where Wangkatjungka community is and why it is relevant to this topic! The Most Important Points to Consider: ANTENATAL Optimise the haemoglobin and iron stores before delivery Discuss and document what the patient will and won't accept - make sure you understand Decide on the best place for delivery - consider availability of theatre and resources to manage haemorrhage (cell salvage, surgical expertise, radiology etc) INTRAPARTUM stop any bleeding AS SOON AS POSSIBLE oxytocics - get control of tone rapidly Tranexamic acid - consider prophylactically or as soon as any bleeding occurs. theatre access immediately senior / experienced staff early hysterectomy early (not late). Manual aortic occlusion. Cell salvage - this can include vaginal bleeding and blood with amniotic fluid POSTPARTUM What is they have significant anaemia? ICU/HDU give oxygen give haematinics (iv iron / EPO) to rapidly replace the lost Hb minimise any further blood loss - including iatrogenic blood tests! paralysis & ventilation - usually needed around Hb 30-40g/L hyperbaric O2 - case series and reports of successful use polymerised Hb - can be accessed for compassionate use but manufactured in the US USEFUL RESOURCES Best Reference on this topic: Kidson-Gerber, G., Kerridge, I., Farmer, S., Stewart, C. L., Savoia, H. and Challis, D. (2016), Caring for pregnant women for whom transfusion is not an option. A national review to assist in patient care. Aust N Z J Obstet Gynaecol, 56: 127–136. doi:10.1111/ajo.12420 For a good explanation and diagram explaining the Jehovah's witnesses' basic position on blood and blood products : http://ajwrb.org/watchtower-approved-blood-transfusions Tranexamic Acid Tranexamic acid for prophylaxis in Caesarean https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5228660/ Tranexamic Acid for PPH WOMAN study Hyperbaric Oxygen to treat severe anaemia in a JW after abruption: https://www.ncbi.nlm.nih.gov/pubmed/23380087 Case report of use of hemopure for postpartum anaemia https://www.tandfonline.com/doi/pdf/10.1080/22201173.2009.10872581 Case report of the use of hemopure in severely anaemic JW trauma patient in Melbourne https://www.mja.com.au/journal/2011/194/9/synthetic-haemoglobin-based-oxygen-carrier-and-reversal-cardiac-hypoxia Vaginal Cell Salvage Cell salvage for postpartum haemorrhage during vaginal delivery: a case series http://www.bloodtransfusion.

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 tissue damage followed by a secondary collagen repair, eg myomectomy, vigorous curettage resulting in Asherman syndrome, submucous leiomyomas, thermal ablation , and uterine artery embolization. ACOG https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Placenta-Accreta RANZCOG https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Placenta-Accreta-(C-Obs-20)-Review-March-2014,-Amended-November-2015.pdf?ext=.pdf Diagnosis - Imaging Modalities: https://radiopaedia.org/articles/placenta-accreta USS or MRI Surgical management Surgical management of placenta accreta: to leave or remove the placenta? A Perez-Delboy, JD Wright 2014 Timing of Delivery Placenta Accreta: When is the optimal time to deliver? Manual Aortic Occlusion Our podcast discussion on this topic Interventional Radiology 3) REBOA during unexpected uterine rupture https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628233/ 2) Comment urging caution before embracing interventional radiology techniques: http://www.obstetanesthesia.com/article/S0959-289X(16)30075-9/pdf Communication and Having an Effective Team Fostering a culture of safety: The OR team huddle Conservative Management Leaving the placenta in situ, Methotrexate, En bloc resection, Hysteroscopic resection

(*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 dural puncture headache. It can be used as an alternative or as interim management of PDPH. So far there has been no randomised controlled trials looking at SPGB specifically for PDPH but there have been case series. Cohen et al (1) published in 2009 showed that  in their case series of 32 patients, 69% avoided epidural blood patch and another case series by Kent (2) had a 100% success rate in resolution of headache. There is also a systematic review of SPGB for treatment of headaches published in 2017 by Ho (3) and there are RCTs underway. Some patients get permanent resolution of the headache with the a single SPGB, other patients may need repeat SPGB. Remembering that the natural time course of PDPH is that the majority of patients gets better 7-14 days after the dural puncture. Sphenopalatine ganglion lies in the pterygopalatine fossa which lies posterior to the the middle concha. The sphenopalatine ganglion is the largest of the four parasympathetic ganglions associated with the trigeminal nerve. It is postulated to work by blocking the parasympathetic nerve fibres and improving cerebral vasculature reducing the headache. Advantages of the SPGB is that it is less invasive, easier and quicker to perform and has lower risks than and epidural blood patch. As well as an useful alternative to patients who do not want an epidural blood patch or who have contraindications such as bacteraemia or spina bifida The contraindications for performing a SPGB are previous nasal trauma, deviated septum or local anaesthetic allergy. For further information on how to perform a SPGB watch our video tutorial on youtube below. Remember you have to perform the block on both sides. https://youtu.be/ebvS6tvr4Yk References Cohen S, Sakr A, Katyal S, Chopra D. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia. 2009 May 1;64(5):574-5 Kent S, Mehaffey Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED. The American journal of emergency medicine. 2015 Nov 1;33(11):1714-e1 Ho KW, Przkora R, Kumar S. Sphenopalatine ganglion: block, radiofrequency ablation and neurostimulation-a systematic review. The journal of headache and pain. 2017 Dec;18(1):118 Láinez MJ, Puche M, Garcia A, Gascón Sphenopalatine ganglion stimulation for the treatment of cluster headache. Therapeutic advances in neurological disorders. 2014 May;7(3):162-8              

(*Fictitious case) You are contacted by the ultrasound department - they have just completed a formal scan on an urgent referral and want to discuss their findings with you urgently. A 34yr old woman was admitted overnight with some PV bleeding at 32 weeks. She has had 2 previous caesareans and on the scan they have found a low lying anterior placenta which overlies the previous scar and concerningly there appears to be ultrasonographic evidence of accreta (vascular lacunae) and possibly doppler evidence of large vessels indicating invasion of the bladder (percreta). This condition quite rightly strikes fear into the heart of surgeon and anaesthetist alike - primarily because of the risk of catastrophic torrential haemorrhage. What are the principles of managing someone with placenta percreta? Hi Everyone, This week on the podcast I am joined again by my Colleague Graeme Johnson where we discuss the perioperative and anaesthetic management of the patient with a morbidly adherent placenta. Useful links: Manual Aortic compression: Screencast of presentation on this topic at Dept Anaesthesia Meeting: https://youtu.be/Wg4aH6Z8fmA        

(*Fictitious case) A 32 yr old pregnant woman with insulin dependent diabetes presents to a regional hospital in WA at 27 weeks gestation, with probable premature rupture of her membranes, threatened preterm labour and a low grade fever. She is given a dose of celestone (betamethasone) intramuscularly, some nifedipine for tocoloysis and has an urgent areomedical transfer organised. During the flight she has a salbutamol infusion to provide further tocolysis and minimise the risk of delivery of a 27 week foetus in the back of the plane which the retrieval team are very keen to avoid! On arrival at your tertiary hospital she is febrile (T 38.4) but the most striking thing noted is the fact she is breathing very heavily but yet has clear lungs and normal SpO2 of 99%. The team assessing her do some blood tests including an arterial blood gas and obtain the following results: pH 7.26, pCO2 16, pO2 128, HCO3 7.5, Na 141, K 4.8, Cl 101, Gluc 19.0, Urea 8.1, Crn 0.09 Urine analysis: Glucose 4+, Ketones 1+ What is going on? How are you going to manage this patient? This week I am joined by my colleague Dr Graeme Johnson and we discuss the ins / outs of DKA during pregnancy. Diabetes is an increasingly common condition both in the general population but also in pregnancy. DKA is an important and life threatening critical illness which can develop in any pregnant unwell diabetic patient. All healthcare workers who may be involved in the care of a diabetic pregnant patient will benefit from understanding the basic physiological process which leads to DKA, how to recognise it, and the principles of management. Join Graeme and I as we discuss a hypothetical case. You can listen to the audio only on the blubrry podcast or if you prefer follow along with us watching the screencast which has the slides containing visual aids & diagrams. This does probably make it somewhat easier to follow the discussions we have about the metabolic pathways & ketone production. Screencast: https://youtu.be/dAGb6lEgsnk Here are the links to the two main articles used in putting together this weeks podcast: The Management of DKA References A Hallett, A Modi, N Levy; Developments in the management of diabetic ketoacidosis in adults: implications for anaesthetists, BJA Education, Volume 16, Issue 1, 1 January 2016, Pages 8–14, https://doi.org/10.1093/bjaceaccp/mkv006 Mohan M, Baagar KAM, Lindow S. Management of diabetic ketoacidosis in pregnancy. The Obstetrician & Gynaecologist 2017;19: 55–62. http://onlinelibrary.wiley.com/doi/10.1111/tog.12344/pdf   Want to Brush up on Arterial Blood Gas Analysis? Check out these amazing sites: 1 - Kerry Brandis' amazing Acid Base textbook available here on the anaesthesiamcq site: http://www.anaesthesiamcq.com/AcidBaseBook/ABindex.php 2 - For those of you who like the super deep dive into a topic, I recommend Alex Yartsev's super detailed discussions on metabolic syndromes and blood gas analysis on his great ICU website below: http://www.derangedphysiology.com/main/core-topics-intensive-care/arterial-blood-gas-interpretation  

Hi everyone, This weeks post is part 2 of the 5th in my mini series on patient blood management in obstetrics and gynaecology. We discuss some of the strategies we can use to avoid or treat excessive bleeding which can occur during gynaecological surgery or obstetric haemorrhage - this week focussing on anaesthetic / pharmacological and coagulation management strategies. I am told by some trusted mentors that most podcast (or vodcast) listeners or viewers are time poor & have relatively shortish attention spans such that around 15min is the "sweet spot" for most of us. So based on that this talk is only meant to be a summary - I do hope to inspire you to go away and think about some of these techniques if they catch your interest. Do some more learning and research on your own. Some people have built whole careers around some of these different techniques / strategies! I will hopefully come back at some stage and do a "deep dive" to delve into aspects of some of these in greater detail! (e.g. cell salvage - I have you in my sights Dr Rucklidge!). Screencast of this talk: https://youtu.be/EMg4IngN0Ds   References / Resources: Blog discussion on permissive hypotension on Life in The Fast Lane https://lifeinthefastlane.com/ccc/permissive-hypotension/ Previous Blog on this site: https://www.obsgynaecritcare.org/oxytocin-use-in-labour-increases-postpartum-haemorrhage-due-to-uterine-atony/

You phone goes off - you roll over it is 2am - when you pick up it is a theatre nurse calling to ask if you can urgently come to the hospital immediately - the team are too busy to talk to you. The nurse tells you a woman has just arrived via ambulance from another small peripheral hospital. She had an emergency caesarean about 6 hours ago and hasn't stopped bleeding since. She has had 4 units of red cells and 4-5 litres of saline but nothing else. When you arrive 15min later surgery is underway but the surgical team tell you "everything we touch is bleeding" and you notice that she is even bleeding from the skin around her iv...... The anaesthetic registrar turns to you and says - "lets give her the fibrinogen concentrate -  we need to get on top of this coagulopathy right now!......" (*Fictitious case example) Hi Everyone, This week we are joined by a colleague and a great friend of mine Dr Hamish Mace, one of the co-authors of an article in the 2017 edition of Australasian Anaesthesia (aka the Blue Book) entitled "Fibrinogen concentrate for the treatment of acquired hypofibrinogenaemia". Hamish is a consultant anaesthetist working in Western Australia - he works at Fiona Stanley Hospital a large tertiary centre in metropolitan Perth - but has also worked in the past in remote regional centres in WA, in retrieval medicine for the RFDS (Royal Flying Doctor Service) and spent time on fellowship in Toronto Canada. Hamish co-ordinates the preoperative anaemia correction service, is on the hospital transfusion committee, has a strong interest in many aspects of patient blood management. In the interview we briefly discuss the role of fibrinogen in the acquired coagulopathy that often develops during major haemorrhage, the historical treatments used (FFP, cryoprecipitate), the history of fibrinogen concentrate and where we think fibrinogen concentrate might fit into the current management of major haemorrhage - both in tertiary but also remote, regional and retrieval situations. For those of you who are interested in reading on this topic in detail here is the link to the ANZCA website page where you can access the article written by Hamish and Mansi - the article itself has many great references. Their article is in the 2017 edition. Check out all the other great critical care and anaesthesia articles in this book - a quick shout out to Richard Riley the editor of this great biannual publication. http://www.anzca.edu.au/resources/college-publications In the interview we also talk about the value of measuring fibrinogen an coagulation rapidly with point of care viscoelastic tests. Check out our ROTEM learning package right here on this website (of which Hamish was also a co-author). ROTEM learning package Advice on mixing and administering fibrinogen concentrate: https://youtu.be/7UP2Y1dH9QI  

Merry Xmas! This weeks post was inspired by a recent unexpected case of severe hyperkalaemia in a severe pre-eclamptic - I have put together a fictitious case which is a little more severe in order to illustrate the principles of managing hyperkalaemia - I hope you enjoy & take it easy over Xmas! CASE HISTORY (*A fictitious patient history ) Your pager goes off - code blue medical labour ward! On arrival you are told the patient for whom the code was called has just arrived following an urgent transfer from another hospital. She presented to their service at 31 weeks with a headache, BP 190/100, proteinuria and mildly raised creatinine. She was diagnosed with severe pre-eclampsia, given labetalol, nifedipine and then transferred. She now appears confused with the following vital signs: HR 33/min, BP 74/55, SpO2 92%, RR 17/min (*Image courtesy www.lifeinthefastlane ) An immediate venous blood gas shows the following result: Na 139, K 8.4, pH 7.23, pCO2 37, pO2 63, Lactate 1.8 How are you going to manage this patient?   Immediate Standard Mgmt 1 - Is it real? Common causes of high potassium includes hemolysis of red cells from the sampling and handling process.  Always do an ECG whilst awaiting a repeat result - if the patient is compromised and the ECG is abnormal / consistent with hyperkalaemia then assume it is real and don't delay your treatment! The quickest way to get a repeat sample is usually a VBG this usually only takes a few minutes and will also give you the glucose and pH - important values to know for both mgmt and diagnosis. 2 - Prevent an arrhthymia Immediate mgmt - stabilise the cardiac membrane with intravenous calcium. Most guidelines recommend calcium if there are ECG changes or the absolute K level is over 7mmol/L. *Calcium chloride has 3 times more calcium than calcium gluconate. 3 - Shift K intracellularly a) Insulin / Glucose. Usual dose 10units actrapid + 25-50ml 50% Dextrose Stimulates Na/K/ATPase Give glucose to prevent hypoglycaemia' Lowers K by 0.5 -1 mmol/L per hour b) Salbutamol 20mg neb Good choice if the patient is bradycardic (common in severe hyperK) Stimulates Na/K/ATPase also c) NaHCO3 (if acidotic) When acidosis exists H+ is exchanged for intracellular K+ Makes sense to consider NaHCO3 if acidosis is present 50-100ml of NaHCO3 8.4% 4 - Eliminate K from the body (usually renal) - Enhance renal elimination - diuretics (e.g. frusemide), K free crystalloid (if indicated - saline) or both! - Dialysis - institute early in patients with complete renal failure -  GI exchange resins (eg resonium) most guidelines now consider they have no role in the acute management. 5 - Identify and treat the cause! - You need to address this issue to stop if from recurring! Usually multiple factors combine to lead to hyperkalaemia. Fix reversible causes especially drugs! Don't rely on your memory - get their medication chart out then google all the known drugs that can cause hyperkalaemia! Drugs Known to Cause / Contribute to hyperkalaemia (either impair excretion or promote transcellular shift) ACE inhibitors / AT2 antagonists Spironolactone / Amiloride NSAIDs Beta blockers (see discussion below) Trimethoprim Heparin Pentamidine Suxamethonium Renal dysfunction - almost always there is a degree of renal impairment preventing excretion of the excess K load. Make sure you aren't missing important reversible causes - e.g. obstruction (consider USS renal tract urgently).  Cell release (eg hemolysis, tumour lysis, trauma or extensive surgical injury). In our O& G patients this includes widespread tissue injury especially after major surgery or perhaps chemotherapy. BUT This is a pregnant woman with PET - renal impairment, acidosis, hemolysis, transfusion - these are common events in our pregnant patients. Cardiac Arrest Secondary to Hyperkalaemia

Hi everyone, This weeks post is the 5th in my mini series on patient blood management in obstetrics and gynaecology. We discuss some of the strategies we can use to avoid or treat excessive bleeding which can occur during gynaecological surgery or obstetric haemorrhage. After sitting down to put this section together I soon realised that there is actually a lot more to discuss than I anticipated - so I have decided to split this into two parts - surgical / physical and radiological techniques and then another one on anaesthetic / pharmacological and transfusion strategies. I am told by some trusted mentors that most podcast (or vodcast) listeners or viewers are time poor & have relatively shortish attention spans such that around 15min is the "sweet spot" for most of us. So based on that this talk is only meant to be a summary - I do hope to inspire you to go away and think about some of these techniques if they catch your interest. Do some more learning and research on your own. Some people have built whole careers around some of these different techniques / strategies! I will hopefully come back at some stage and do a "deep dive" to delve into aspects of some of these in greater detail! (e.g. cell salvage - I have you in my sights Dr Rucklidge!). Here is the screencast: https://youtu.be/rNfqlaL64qg Here are some useful resources: If anyone knows of any other great websites / references please let us all know in the comments! Overview of topical haemostatic agents for O&G surgery: http://www.mdedge.com/obgmanagement/article/64699/surgery/your-surgical-toolbox-should-include-topical-hemostatic-agents Youtube Uterine Artery Ligation: (Can any obstetricians out there let me know if these videos are any good - if you can find any better teaching videos let me know!) https://youtu.be/KUePaQUHJYE https://youtu.be/0T7mo9GIX_Y Links to previous PBM posts: Patient blood management what is it? Iron physiology Oral iron Intravenous iron    

You get called down to labour ward to place an urgent epidural in a labouring nulliparous woman. When you get there the team inform you that "she is going crazy with the pain", they can't get her to hold still, they are having trouble monitoring the fetus and they are really worried she might be having an abruption. They plead "can you please do an epidural so we can get control of the situation?". The partner then tells you that she wasn't planning on having an epidural because when she was younger she was told "she had mild spina bifida" He doesn't know any other details but as long as he has known her - over 10 years - she has never had it looked into and he doesn't think she has ever had surgery. You glance at her back and notice a small dimple and a tuft of hair in the lower lumbar region and she looks like she might have a slight scoliosis, oh dear..... This week I have managed to corner one of the rising stars in our department Gareth Ansell an anaesthetic provisional fellow in his final year of training.  Gareth earlier in his career worked as a neurosurgical registrar before he saw the light and changed to the illustrious profession of anaesthesia, thus his interest in neurosurgical conditions and anaesthesia. Listen to this great 12-15minute interview where we cover all the important implications of how to assess & manage a parturient who has spina bifida. Spina bifida can be associated with serious anatomical problems including tethered cord, lower than normal cord, Arnold Chiari malformations, and lack of normal epidural anatomy. These can predispose to some truly serious complications including neurological injuries, dural punctures, and failed or patchy regional blocks. As an aside Gareth's father is an obstetrician - who as it turns out was working in the small regional NZ town Rotorua at the time my twin sister and I were born and it is possible that he may have been the person who helped deliver me all those years ago! A small world. Thanks Gareth - we are also in the process of working on another episode together - the use of sphenopalatine block for postdural puncture headache - including some exciting footage of Gareth placing lignocaine soaked swabs in my nasopharynx - watch this space!

Hi Guys, Number 4 in the patient blood management in obstetrics and gynaecology mini tute series. Intravenous iron - a relatively safe and effective treatment that can rapidly correct iron deficiency and anaemia, increasingly used in many of our patients. But how much do you really know on this topic? What are all these different preparations available? What are the risks / cautions / contraindications? What about anaphylaxis, skin staining and what the hell is the "Fishbane reaction!" Give us only 11min of your time and you will be surprised how much more knowledge you'll have on this topic! Time to hone your knowledge! If you want to be a real expert do the online package at www.bloodsafelearning.org And to maximise your learning we recommend you have a good understanding of iron physiology and the principles of PBM first ....so if you haven't already make sure you check out all the previous episodes: Patient blood management what is it? Iron physiology Oral iron   Screencast: https://youtu.be/XESKNNE33og Comments and feedback welcome please!  

Hi Guys, Number 3 in the patient blood management in obstetrics and gynaecology mini tute series. Nice and short this time! Oral iron the treatment of choice for the vast majority of our patients - seems relatively simple yeah? Maybe but there's more than to it meets the eye! -  do it wrong and you'll fail miserably - if they take the wrong tablets, don't take them for long enough or if they were never going to take them in the first place! Time to hone your knowledge! If you want to be a real expert do the online package at www.bloodsafelearning.org Screencast (recommended): https://youtu.be/7LPCsng7tb8 Thanks for watching - comments and feedback please!    

Hi again! This is episode two in my mini tutorial series on patient blood management (PBM) in obstetrics and gynaecology. This one is on the basics of iron physiology - I can hear you all yawning already! However if you really want to know how to effectively treat anaemia with iron (oral, intravenous) and understand how to recognise and diagnose iron deficiency and iron deficiency anaemia (IDA) this is core knowledge....Give me 12-15min of your life and have a listen below - all of the mini tutorials which follow will make so much more sense you'll be thankful you made this small investment! Go to these sites they are great: 1 The National Blood Authority (NBA): https://www.blood.gov.au/patient-blood-management-pbm 2 Bloodsafelearning: https://bloodsafelearning.org.au/ Comments and feedback please! Thanks for listening and see you soon with the next one! Screencast version (recommended): https://youtu.be/6tfokBtpikc  

Gidday, Bonjour, Hi! This is the first episode in my mini series on patient blood management in O&G. Menorrhagia, haemorrhage, PV bleeding, iron deficiency, anaemia - any of this seem familiar? It should do! These issues affect a huge number of obstetric and gyaecologic patients, and as such this is an issue we should all be interested in learning more about - so I hope you find these interesting! I have been teaching around this topic to my colleagues and our registrars for a number of years now but thought maybe I should share some of this with you & a wider audience. The plan is to break this large topic up into smaller (aka palatable) sized mini topics of 10-15min. Let me know what you think! I am definitely not the authority in this area but I hope to inspire you to become interested and I thoroughly recommend you go to (in my humble opinion) the two following websites to get the real low down. These are definitely the go to authoritative resources for PBM in Australasia and a big thank you to the teams there for all their hard work!: 1 The National Blood Authority (NBA): https://www.blood.gov.au/patient-blood-management-pbm Please watch their 5 min intro video on PBM - see below: https://youtu.be/gV4Nmjg29p0?list=UUeVXFWopd_xIalFlOMOpzDQ 2 Bloodsafelearning: https://bloodsafelearning.org.au/ These guys have put together some amazing elearning packages - I have personally done many of them and vouch for them. These are definitely the go to authoritative resources for PBM in Australasia and a big thank you to the teams there for all their hard work! Ok on with the show! here is my first mini tute which is my own attempt at explaining what PBM is and why we should rethink our traditional mental model of blood transfusion: My Screencast (recommended) here: https://youtu.be/yDFbpIXaiAw Comments please!

(*This is a fictional case) Your patient has just had a very difficult instrumental delivery in theatre after a prolonged obstructed labour. Unfortunately now her uterus won't contract despite oxytocin and ergometrine and she is bleeding pretty briskly. You clean her deltoid with an alco-chlorhex wipe, inject 250mcg (1 ampoule) of carboprost i.m. and cross your fingers that this will do the job. You lean over the drapes, talk to the obstetric team and start rubbing her uterus while they repair the episiotomy. Suddenly you hear a raspy wheezing sound from the head of the bed - you immediately jerk your head around and glance at your patients face - she looks terrified. Bronchospasm! She has pursed lips and is struggling to breathe, her sats probe says 75% and you suddenly wish you had signed up to do dermatology back in your intern year..... Your assistant runs around trying to find a nebuliser and salbutamol and over the next 4 minutes she becomes unresponsive, her breathing becomes progressively worse and she takes on a mottled colour. Everyone in the room including the IT technician fixing the PC in the corner can see she needs you to manage her airway & breathing...... 1. How would you induce anaesthesia? Which drugs would you use? 2. Once you get the endotracheal tube in place how are you going to set up the ventilator to safely ventilate this woman? You notice her ETCO2 is already 75mmHg and you can't even get a pulse oximtery reading. You decide that her hypoxia and the acidosis from all that CO2 is causing her some serious harm - time to get some oxygen in. You set the ventilator to VCV with tidal volume 700ml x 16 breathes per minute and a PEEP of 8mmHg. 3.After a few minutes your patient has no pulse!  What has happened (what is the differential diagnosis) and what are you going to do...? 4. You sort that issue out but now what bronchodilators are you going to use? 5. Her uterus is still bleeding and in fact the tone is much worse - what are you going to do about that! SAFE MECHANICAL VENTILATION IN BRONCHOSPASM KEY POINTS: Use a volume-control mode of ventilation. Use minimal PEEP. Use a small tidal volume, 5-7ml/kg Use a slow respiratory rate, 10-12 breaths per minute (or even less!) Use a long expiratory time, with I:E ratio 1:3 or 1:4 Increase inspiratory flow rate to maximum. . Reset the pressure limits (i.e. ignore high peak airway pressures).  . Use heavy sedation. Use neuromuscular blockade. Use lowest FiO2 to achieve SpO2 of 90-92% Minimise the duration of neuromuscular blockade. Keep the Pplat below 25cmH2o to prevent dynamic hyperinflation.   Resources: http://www.derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%206.1.1/ventilation-strategies-status-asthmaticus http://intensiveblog.com/    INTENSIVE podcast - The Alfred ICU. "Asthma and Mechanical Ventilation Pitfalls by David Tuxen"    

      Can the type of anaesthetic you get when you have your cancer surgery effect how long you live afterwards? Well the answer is.................. maybe. Listen to my 6min discussion here: https://www.obsgynaecritcare.org/wp-content/uploads/2017/09/Doestheanaestheticeffectcanceroutcomes.m4a I wouldn't be surprised that if you aren't an anaesthetist you may have never heard this topic discussed before. For those of us working in the anaesthesia field though this is a topic which has quietly been building momentum over the last decade or more and has really been getting a lot more press in the leading anaesthesia journals in the last couple of years. I was unable to attend the recent ANZCA ASM held in Brisbane but luckily they now provide us access to listen to recordings of many of the presentations online and one of the sessions on "onco-anaesthesia" caught my eye. I especially impressed with one speaker who discussed the following recently published paper. They analysed the outcomes of a large number of patients, who underwent cancer surgery at the Marsden Hospital (a large cancer centre in the UK) & compared propofol to volatile anaesthetics. This was observational and retrospective so not the evidence you need to claim cause and effect but even after adjusting fo r known confounding with regression there was an obvious increased mortality in patients who had the volatile anaesthetic - definitely food for thought: Check out the article below: Wigmore TJ1, Mohammed K, Jhanji S.Long-term Survival for Patients Undergoing Volatile versus IV Anesthesia for Cancer Surgery: A Retrospective Analysis. Anesthesiology. 2016 Jan;124(1):69-79 What's the scientific basis and explanation for this possible effect? The science and the debate is actually quite complex and encompasses a number of related but different questions: When having  a GA is total intravenous anaesthesia (usually an infusion of propofol +/- remifentanil)  better than a volatile or inhaled anaesthetic (eg sevoflurane / isoflurane)? Does the use of a regional technique (spinal / epidural / local anaesthetic block) lead to a better outcome than a GA (general anaesthetic)? Is the use of opioids detrimental too? At present we can only say that the answer to all 3 of those questions is - well maybe....... In the interests of time / space lets briefly delve into the explanation for claim number 1 - volatile versus intravenous anaesthesia. Why is what happens at the time of cancer resection so important? Surgical resection is currently still the common primary treatment of many cancers - and this is especially in true gynaecological malignancies such as endometrial, ovarian, vulval and cervical cancer. At the time of surgical resection it is recognised that malignant cells can be "dislodged" into the circulation. Surgery & anaesthesia are associated with alterations to the neuroendocrine and immune systems which could impair the immune response and decrease the ability to prevent metastasis / implantation / angiogenesis and proliferation of malignant cells. Is this biologically plausible and what are the proposed biological mechanisms? An increasing body of in vitro and laboratory research has demonstrated effects of these anaesthetics on immune cell function and cancer cell growth - most of which appear to support the hypothesis that propofol is better than volatile anaesthetics - there could well be something to this. 1 - The effect of different anaesthetics on tumor cytotoxicity by natural killer cells. Toxicol Lett. 2017 Jan 15;266:23-31. 2 - Propofol inhibits invasion and growth of ovarian cancer cells via regulating miR-9/NF-κB signal.Braz J Med Biol Res. 2016 Dec 12;49(12):e5717. Volatile anaesthetics like sevoflurane have been shown to enhance HIFs - hypoxia inducible factors - they are known to be involved in the regulation of cell survival and apoptosis etc.

"You are called urgently into one of the birth suite rooms. A woman has just given birth, there is blood everywhere, she is moaning & breathing (barely). She is a ghastly pale / mottled colour and you can't feel a peripheral pulse..... it is a sunday afternoon, you work in a smaller hospital and the theatre team aren't on site......." Being faced with a shocked / peri-arrest obstetric patient who is literally exsanguinating in front of you is one of those nightmare situations that  those of us who work in obstetrics dread being faced with. The sudden uterine rupture, the unexpected placenta accreta, or an amniotic fluid embolism with ensuing severe coagulopathy all spring to mind. This is also not an uncommon event in theatre in women having surgery for placenta accreta/percreta or ruptured ectopics - where we are usually prepared for massive haemorrhage but despite this where we can suddenly find ourselves in a situation where the rate of blood loss is so catastrophic that we have lost control of the patients circulation. Manual Aortic Compression Manual aortic compression (occlusion) is a technique which can be applied almost immediately to control the bleeding, to prevent (or treat) cardiac arrest from hypovolaemia and buy precious minutes - to allow transfer to definitive care in theatre, perform surgical interventions, and allow resuscitate with fluid or blood products. Staffan Bergstrom an obstetrician from Sweden has been teaching this life-saving technique for many years in Africa, with great effect (personal communication). Watch his youtube tutorial where he eloquently describes how he teaches this technique: https://youtu.be/rc9BYcIhamA Literature supporting manual aortic compression Aortic occlusion both manually and using a specific device was introduced as a formal procedure for managing severe haemorrhage in this large egyptian hospital - following it's introduction deaths due to haemorrhage ceased. 1 - Experience managing postpartum hemorrhage at Minia University Maternity Hospital, Egypt: no mortality using external aortic compression. J Obstet Gynaecol Res. 2011 Nov;37(11):1557-63 Questions that need answering? How long can it safely be applied. What complications can occur - and have been reported. Use in the non-obstetric setting Trauma It has been used in the prehospital setting for a patient with massive blood loss from lower extremity gunshot injuries: 1 - Temporization of penetrating abdominal-pelvic trauma with manual external aortic compression: a novel case report. Ann Emerg Med. 2014 Jul;64(1):79-81 Subsequently this same group studied the feasibility of more widespread use if this technique in the prehospital trauma setting: 2 - Abdominal aortic and iliac artery compression following penetrating trauma: a study of feasibility.Prehosp Disaster Med. 2014 Jun;29(3):299-302 What about alternative techniques which can rapidly stop the bleeding vascular occlusion?: Each of these deserve in depth discussion in their own post but briefly they are: Interventional radiology techniques like elective internal iliac balloons placed prior to accreta surgery are well described. You need a skilled interventional radiologist, appropriate equipment and know well beforehand that the patient is at risk - so not useful in unexpected situations REBOA - retrograde endovascular balloon occlusion of the aorta - increasing use throughout the world (traumatic haemorrhage, obstetric haemorrhage and vascular surgery), and with some increasing literature describing its use particularly in women with placenta accreta/percreta. Aortic cross clamping - general anaesthesia and laparotomy with formal aortic cross clamping by a skilled / trained surgeon is also a lifesaving technique. Getting access to the aorta in the retroperitoneum to allow formal clamp application requires the presence of a surgeon who is trained in this technique ( I am told it is not something any surgeon/obstet...

  https://www.obsgynaecritcare.org/wp-content/uploads/2017/08/Oxytocin-in-labour-increases-PPH.m4a   The use of oxytocin to induce or augment labour is an established, commonly used practice that underpins a lot of modern obstetric practice. This technique is a undoubtedly a useful tool which has allowed us to improve maternal and fetal outcomes. For example to induce a timely delivery when maternal illness such as PET occurs or to avoid an operative delivery for a mother when their spontaneous progress in labour is slow. However, like most things in medicine (and life in general) there is no such thing as a "free lunch" and it is perhaps a less well recognised fact that the use of oxytocin in labour - especially at higher doses and for prolonged periods - is associated with an increased risk of postpartum haemorrhage due to uterine atony. Uterine atony is becoming more common in developed countries: The incidence of uterine atony causing postpartum haemorrhage in developed countries has increased markedly in the last 2 decades - one of the important factors contributing to this is thought to be the increased prevalence and use of oxytocin during labour. Lutomski JE1, Byrne BM, Devane D, Greene RA. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study. BJOG. 2012 Feb;119(3):306-14.  Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study. What is the mechanism underlying this phenomenon? Exposure to oxytocin used during labour over time leads to downregulation and desensitisation of the oxytocin receptors on the myometrium. This leads to a decreased response to oxytocin when used after delivery as a uterotonic to prevent PPH.¹ "Fatigued / tired myometrium". Women who are not progressing well and have been in prolonged labour may have a "tired" myometrium (it is a muscle and it tires after prolonged use). These women may often then receive augmentation with oxytocin in an effort to achieve vaginal delivery. The presence of the oxytocin infusion could also be considered a marker of the presence of a "fatigued / tired" uterus in these individuals.² 1. Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony. Am J Obstet Gynecol 2011; 204: 56.e1-6. 2. Predictors of severity in primary postpartum hemorrhage. Arch Gynecol Obstet. 2015 Dec;292(6):1247-54. Recognise these patients BEFORE delivery. Anticipate and prepare for uterine atony! In Theatre: When patients come from labour ward to theatre for a non elective caesarean during the patient assessment and the team time out specifically enquire about the length of labour & oxytocin use, duration and dose. In Labour Ward: The midwifery and obstetric team should specifically have a discussion regarding their planned management of the third stage in patients on oxytocin infusions. Oxytocin is still the best first line uterotonic but anticipate that it may not be effective. In vitro rat and human studies indicate that oxytocin is less effective in myometrium exposed to oxytocin in labour, but still appears to be more effective than the other uterotonics - at least in vitro anyway.¹ Use oxytocin first but start with your highest recommended dose of oxytocin don't wait until haemorrhage is already well established! At our institution at caesarean delivery I would give a 2-3 unit bolus (and I personally repeat this a few times every few minutes if there is haemodynamic stability) and start the 40u/500ml infusion at 250ml/hr. 1 - Comparative efficacy of uterotonic agents: in vitro contractions in isolated myometrial strips of labouring and non-labouring women. Can J Anaesth. 2014 Sep;61(9):808-18. In the presence of oxytocin receptor downregulation will the other uterotonics still work? The ergot and prostaglandin F2α uterotonic drugs work via different receptors and the...