Obsgynaecritcare

(*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"

(*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 br

(*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 sub

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

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. W

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 w

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 g

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 the

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 pa

(*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

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 t

(*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 dur

(*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

(*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

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 -

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

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 ma

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 who

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 tra