Obsgynaecritcare

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 administrati

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 Serot

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 s

"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 t

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 deteriora

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

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 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.obstetanesthe