Factor V Leiden and Regional Anesthesia in Pregnancy

[sigrhoillusion]

What are your guys thoughts?

Last week I had a 22yo VERY NON-COMPLIANT patient with history of FVL present in labor. Patient was "seen" by MFM and heme-onc, sporadically. Her history of FVL included MULTIPLE blood clots including thrombotic events even during periods of compliance with anticoagulation. Per her notes in between clotting episodes she had been put on numerous meds including Lovenox and Xarelto. Back in 2015 she had in intracardiac thrombus which hwas usrgically removed after an IVC filter had been placed pre-op and subsequently removed later.

So now OB calls for epidural at 3am with the patient in labor at 7cm. Patient had two prior pregnancies which she delivered SVD without the use of epidural. but of course this one she was in too much pain and wanted one. Labs looked ok except for a slightly low PTT (24? don't remember exact number). Heranti-coag course this time was that she was bridged from Lovenox to 10,000units heprin TID at 36weeks. However, she stopped taking the heparing about a day before coming in labor. OB planning to restart anti-coagulation within 6 hours after delivery. And of course OB resident also mentions that patient desires BTL afterwards...

What would you guys do?

And before we get into too much debate, I told OB resident to give her fentanyl PCA. And of course 20 minutes later resident calls me back that patient delivered (probably before PCA was even started). Then she asked about the BTL and what our plan for that would be. Purely elective BTL at 4am... Would you guys spinal? GA? Tell them to come up with an anti-coag plan and get back to you?

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[dhb]

What would you guys do?

Stall and wait for delivery just like you did.
BTL at 4 am no way.

 

[deleted162650]

Ok, for starters, when the OB presented the idea of doing a BTL at 0400, you should have asked her how she managed to park her short bus in the physician lot.

Now back to the case, I'm confused as to why you're balking at placing an epidural in a pt with a hypercoagulable disorder who has been off therapeutic anti coagulation for an appropriate amount of time?? What are you afraid of? Place it, pull it when she pops that kid out, then let the OBs start whatever thinner they want after an appropriate amount of time (per ASRA guidelines or that cool table UW puts out).

It seems to me like you have a habit of trying to make otherwise simple, straightforward cases as complicated as possible. Stop it. You need to relax. Come to CA. Apparently we can smoke pot now.

 

[deleted171991]

It seems to me like you have a habit of trying to make otherwise simple, straightforward cases as complicated as possible. Stop it. You need to relax. Come to CA. Apparently we can smoke pot now.

Plus you have malpractice caps. Plus you yourself are not in your first year as an attending. Nothing beats experience.

 

[deleted162650]

Plus you have malpractice caps. Plus you yourself are not in your first year as an attending. Nothing beats experience.

Hey, don't ball-bust a ball-buster.

 

[Planktonmd]

What are your guys thoughts?

Last week I had a 22yo VERY NON-COMPLIANT patient with history of FVL present in labor. Patient was "seen" by MFM and heme-onc, sporadically. Her history of FVL included MULTIPLE blood clots including thrombotic events even during periods of compliance with anticoagulation. Per her notes in between clotting episodes she had been put on numerous meds including Lovenox and Xarelto. Back in 2015 she had in intracardiac thrombus which hwas usrgically removed after an IVC filter had been placed pre-op and subsequently removed later.

So now OB calls for epidural at 3am with the patient in labor at 7cm. Patient had two prior pregnancies which she delivered SVD without the use of epidural. but of course this one she was in too much pain and wanted one. Labs looked ok except for a slightly low PTT (24? don't remember exact number). Heranti-coag course this time was that she was bridged from Lovenox to 10,000units heprin TID at 36weeks. However, she stopped taking the heparing about a day before coming in labor. OB planning to restart anti-coagulation within 6 hours after delivery. And of course OB resident also mentions that patient desires BTL afterwards...

What would you guys do?

And before we get into too much debate, I told OB resident to give her fentanyl PCA. And of course 20 minutes later resident calls me back that patient delivered (probably before PCA was even started). Then she asked about the BTL and what our plan for that would be. Purely elective BTL at 4am... Would you guys spinal? GA? Tell them to come up with an anti-coag plan and get back to you?

I am not sure what the problem was!
She was on Heparin 10,000 TID which she stopped 24 hours ago, her PTT is normal now.
So why no epidural?
And then if you have to do a BTL why no spinal?
If your concern is the anticoagulation for her FVL after the surgery or after the vaginal birth, isn't that really something that the OB and Hematologist should discuss?

 

[partydoc]

Because some one has to say it- prop sux tube

Spinal for the btl. Btw, we also do ours at 4am. The call guys like to bill for it

 

[sigrhoillusion]

Ok, for starters, when the OB presented the idea of doing a BTL at 0400, you should have asked her how she managed to park her short bus in the physician lot.

Now back to the case, I'm confused as to why you're balking at placing an epidural in a pt with a hypercoagulable disorder who has been off therapeutic anti coagulation for an appropriate amount of time?? What are you afraid of? Place it, pull it when she pops that kid out, then let the OBs start whatever thinner they want after an appropriate amount of time (per ASRA guidelines or that cool table UW puts out).

It seems to me like you have a habit of trying to make otherwise simple, straightforward cases as complicated as possible. Stop it. You need to relax. Come to CA. Apparently we can smoke pot now.

I'm not going to lie, I'm not even a year out of training/fellowship, and tend to be somewhat cautious especially with elective things at 4am. When all I have to base my devision on is ASRA guidelines and a few case reports (most of which have an n of 10 at most). Where I trained we had high risk/complicated patients seen by anesthesiology and a plan was made. That way when they did come in labor or were scheduled for induction/section there was alrady a plan in place that everyone agreed on. Where I work now, when we take call we are covering the ORs which do level 1 traumas as well as OB. Very busy most nights. The BTL was definitely out of the question, but I really was leaning towards doing the epidural, but without all the info at 3am, I decided to "play it safe" and go with another option which I knew had less possible risks, and like I said she literally delivered 15-20 minutes later so she probably didn't even get anything. In fact the convo I was having with OB resident was actually cut short when she said "I have to go, I think she's ready to push"...

I find OB very stressful where I work, especially after doing peds fellowship for a year. Again, where I trained we had a dedicated person on OB overnight. If we're lucky there's a resident on at night, even if they only act as a buffer. I've had several instances where I was called for a STAT section and was literally the first anethesia person over to OB where the patient is already on the table being prepped. Sometimes this is as I'm starting an emergent exlap/crani/trauma down in the ORs. That would have never happened where I trained, cause even if the attedning got there when the patient was being prepped, the resident would have been on OB hoepfully dosing up the epidural if they had one. I've already talked to my chairman about doing a better job of having OB send their high risk patients to PAT or speaking with an anesthesiologist. We use EPIC so if you get called at 3am with a complex patient you could take a minute to pull up the consult note and have some idea of a plan, instead of having something thrown at you when a patient is 8cm and howling like a hyena. And I know medicine in general is often filled with uncertainties and random things thrown at you and we have to make quick decisions without all the info, but again at 3am, I'd rather play it safe.

In the end they ended up doing the BTL around 8am the following day under spinal. Which is what I wold have done. But there was no way I was going to start an elective BTL at 4am and then risk having some massive trauma come over in the main ORs. The reason why I post these questions on this forum is to get an idea of what others would do. If this was in the middle of the day, and there was more staff around and I had time to talk with patient and inform her of everything, I would more than likely place the epidural in a heart beat.

 

[Libertas]

on higher than standard prophylactic heparin (5000u sc), and very non compliant/bad historian?
ptt and/or teg, then neuraxial.

 

[Psai]

Man lol at btl at 4 am. Doesn't get more elective than that

Also the girl is 22. Let her sleep on it a little.

 

[sigrhoillusion]

Man lol at btl at 4 am. Doesn't get more elective than that

Also the girl is 22. Let her sleep on it a little.

I was talking to one of the other people in my group afterwards and they said that one OB tried to convince them that BTLs weren't completely elective. He used the fact taht some patients were such a high risk of getting pregnant again without appropriate sterilization that another child could be a burden on their well being.

Would anyone get a UFH anti-Xa assay? I saw less than 0.1-0.2 would be considered safe for neuraxial.

 

[Planktonmd]

I was talking to one of the other people in my group afterwards and they said that one OB tried to convince them that BTLs weren't completely elective. He used the fact taht some patients were such a high risk of getting pregnant again without appropriate sterilization that another child could be a burden on their well being.

Would anyone get a UFH anti-Xa assay? I saw less than 0.1-0.2 would be considered safe for neuraxial.

If the PTT is normal you should be good in my opinion... anti Xa is more helpful for LMWH

 

[deleted171991]

If the PTT is normal you should be good in my opinion... anti Xa is more helpful for LMWH

Agree.

If one wants true peace of mind, get a TEG.

 

[Noyac]

Ok OP, I'm gonna be a little harsh here because I think you need to assess your approach. I assume you are in PP, so get used to not seeing every pt a week before their hospital visit. You will also find that most places don't have all the resources that an academic center has. And it's not completely necessary either. You need to check your anxieties at the door everyday you walk into the hospital. You also need to educate yourself better on the scientific approach to medicine. Gut feeling and anxiety have no place in medicine. I say this because it seems as though you don't understand FVL, anticoagulants and neuraxial anesthesia. I'm sure you do understand all of these otherwise you wouldn't be were you are. But you need to trust your knowledge and use it safely and efficiently. If not you will never achieve anesthesia bliss and others will cringe when they have to work with you. You are also headed down a road where some may say they will no longer work with you.
The 4am tubal is crap but if others in your group are doing these then you are pretty much stuck. Address it with your group and come up with a group policy. Anyway, how long does a tubal take in your facility? If it's more than 30min of operating time then I would get the group to issue a statement saying they will be done the following day during the pts delivery stay so as not to delay the procedure. Even if you are busy at night as long as nothing is going on you can most likely knock out a tubal before something comes through the doors. Plus you probably have a backup call if absolutely necessary. These things need to be discussed with your group so that you are not seen as an obstructionist.
Finally, if all these comments stress you out then maybe you should apply for an academic position (if you are not already in one).
Again, sorry for being so harsh but I believe it's for your own good.

 

[caligas]

Does anybody else picture the OP as this guy saying "Leiden"

 

[sigrhoillusion]

Ok OP, I'm gonna be a little harsh here because I think you need to assess your approach. I assume you are in PP, so get used to not seeing every pt a week before their hospital visit. You will also find that most places don't have all the resources that an academic center has. And it's not completely necessary either. You need to check your anxieties at the door everyday you walk into the hospital. You also need to educate yourself better on the scientific approach to medicine. Gut feeling and anxiety have no place in medicine. I say this because it seems as though you don't understand FVL, anticoagulants and neuraxial anesthesia. I'm sure you do understand all of these otherwise you wouldn't be were you are. But you need to trust your knowledge and use it safely and efficiently. If not you will never achieve anesthesia bliss and others will cringe when they have to work with you. You are also headed down a road where some may say they will no longer work with you.
The 4am tubal is crap but if others in your group are doing these then you are pretty much stuck. Address it with your group and come up with a group policy. Anyway, how long does a tubal take in your facility? If it's more than 30min of operating time then I would get the group to issue a statement saying they will be done the following day during the pts delivery stay so as not to delay the procedure. Even if you are busy at night as long as nothing is going on you can most likely knock out a tubal before something comes through the doors. Plus you probably have a backup call if absolutely necessary. These things need to be discussed with your group so that you are not seen as an obstructionist.
Finally, if all these comments stress you out then maybe you should apply for an academic position (if you are not already in one).
Again, sorry for being so harsh but I believe it's for your own good.

No i completely agree with your critiques

But I am in an academic center. it's just much different than the other institutes that I trained. and I'm usually very aggressive getting things done and often stretch staff thin on call to get cases done. Just earlier that night I had just started a level 1 traumatic crani, while doing an emergent ex-lap and then ran over to OB to do a tubal (this was at like 9pm, and the tubals take about an hour)

Most/None of the other people here do tubals over night. There's sort of a midnight-6am no tubal unwritten rule, so they agreed with pushing it off. They also have told OB to send high risk patients to PAT. As I said I would have done the epidural if I had more time and she was like a prime at 2cm. But she was G3P2 who was 10 minutes from pushing by the time I got all the info.

But again I agree, I should just go with my knowledge and just do it assuming there's no real emergencies going on.

 

[deleted171991]

No i completely agree with your critiques

But I am in an academic center. it's just much different than the other institutes that I trained. and I'm usually very aggressive getting things done and often stretch staff thin on call to get cases done. Just earlier that night I had just started a level 1 traumatic crani, while doing an emergent ex-lap and then ran over to OB to do a tubal (this was at like 9pm, and the tubals take about an hour)

Most/None of the other people here do tubals over night. There's sort of a midnight-6am no tubal unwritten rule, so they agreed with pushing it off. They also have told OB to send high risk patients to PAT. As I said I would have done the epidural if I had more time and she was like a prime at 2cm. But she was G3P2 who was 10 minutes from pushing by the time I got all the info.

But again I agree, I should just go with my knowledge and just do it assuming there's no real emergencies going on.

Better be safe than sorry. You did fine, don't worry. Hindsight is 20/20, but when you have nobody to bounce ideas off, at the end of a tiring call, it's not that easy.

 

[sigrhoillusion]

Better be safe than sorry. You did fine, don't worry. Hindsight is 20/20, but when you have nobody to bounce ideas off, at the end of a tiring call, it's not that easy.

I've learned the worst thing to do in the middle of the night with a clinical offsite is to do a pub med search. .. haha. always end up with random case reports. in this case the few I found were all on patients who had had extensive workup and planning. the best I saw was one with a small group of patients (n = 7 or 17?) who had all been worked up and had a "multi-specialty" preparation who according to the report all had regional with no issues "which was lower than in other reports"?!?

Of course I couldn't find these other reports or any other complications, just the knowledge of what could be a complication. so again between the timing issue and the non-emergent nature of the situation and the other outings available, I erred on the side of caution. I only brought it up for more opinions and I'm pretty sure the next time I'll run up and pop an epidural in if I'm not in the middle of resuscitation and the baby isn't pooped out before I get there.

On a side note, with the whole PAT issue. Our group did reiterate to OBs that certain patients should probably be seen. i mean half the surgeons send healthy 30yo ASA patients to PAT for hernia repairs, so it would be nice if the OBs sent these patients to us. The least they can do is notify us that they are in the hospital in labor so at minimal we can talk to them early and get some info and a plan or maybe place the epidural when they are uncomfortable at 2cm rather than when they are 8cm and rolling on the floor hysterical. I'm not talking about every laboring patient, (although where i trained EVERY pregnant woman was seen by anesthesia when admitted. Even if they didn't want an epidural we'd still get H+P and consent for everything, because who knows. (Was this the same where others trained? ) Cause even when they didn't want an epidural, after induction and in the middle of the night they would inherently want that epidural but everything was done so they'd be all ready to go and you'd pop it in. I'm not saying everyone here needs to be seen (especially since there's no dedicated OB anesthesiologist/resident 24/7), but OB should be able to filter out some of the ones that might present a problem and give a heads up. I'd much rather know about the patients, get the info, give the info and possibly place the epidural earlier, than wait until the baby is crowning...

Just my opinion...

 

[Noyac]

On a side note, with the whole PAT issue. Our group did reiterate to OBs that certain patients should probably be seen. i mean half the surgeons send healthy 30yo ASA patients to PAT for hernia repairs, so it would be nice if the OBs sent these patients to us. The least they can do is notify us that they are in the hospital in labor so at minimal we can talk to them early and get some info and a plan or maybe place the epidural when they are uncomfortable at 2cm rather than when they are 8cm and rolling on the floor hysterical. Just my opinion...

FVL is no big deal when treated appropriately. My only questions to OB would be, when was the last Xarelto dose and heparin dose. If they fall into the acceptable time frame then fine.
Also, when I get a multip at 8cm for an epidural I just place a spinal and tell OB you have 2 hrs of relief at best. Get the baby out.

I would not have expected to see this pt in my PAT.

 

[sigrhoillusion]

Oh man, I love me some late stage multip spinals. I mentioned this to some of the people here and they looked at me all googly eyed. They usually tell OB to give some pain meds and then place epidural or they'll place CSE. CSE is pretty much the same thing with benefit of epidural, but I've already had one wet tap placing one because patient did a karate back lunge during a contraction right after pushing the spinal drugs. I also miss the pre-made labor spinals that we had. I believe it was 1cc 0.25% bupiv + 1cc sufenta. pop it in, baby slides out...

 

[Noyac]

Oh man, I love me some late stage multip spinals. I mentioned this to some of the people here and they looked at me all googly eyed. They usually tell OB to give some pain meds and then place epidural or they'll place CSE. CSE is pretty much the same thing with benefit of epidural, but I've already had one wet tap placing one because patient did a karate back lunge during a contraction right after pushing the spinal drugs. I also miss the pre-made labor spinals that we had. I believe it was 1cc 0.25% bupiv + 1cc sufenta. pop it in, baby slides out...

That's a lot of sufenta.

 

[sigrhoillusion]

That's a lot of sufenta.

Oops... mean to say 1cc of 5mcg Sufenta

 

[sleepallday]

No i completely agree with your critiques

But I am in an academic center. it's just much different than the other institutes that I trained. and I'm usually very aggressive getting things done and often stretch staff thin on call to get cases done. Just earlier that night I had just started a level 1 traumatic crani, while doing an emergent ex-lap and then ran over to OB to do a tubal (this was at like 9pm, and the tubals take about an hour)

Man, whats up with your place doing spinals at weird times. What would you do if you have a real OB emergency while doing one of these late night tubas?

Oh man, I love me some late stage multip spinals. I mentioned this to some of the people here and they looked at me all googly eyed. They usually tell OB to give some pain meds and then place epidural or they'll place CSE. CSE is pretty much the same thing with benefit of epidural, but I've already had one wet tap placing one because patient did a karate back lunge during a contraction right after pushing the spinal drugs. I also miss the pre-made labor spinals that we had. I believe it was 1cc 0.25% bupiv + 1cc sufenta. pop it in, baby slides out...

Not to be a smart ass but you know you can just get a vial of perservative free 0.25% bupivacaine and use that.

 

[sigrhoillusion]

Man, whats up with your place doing spinals at weird times. What would you do if you have a real OB emergency while doing one of these late night tubas?



Not to be a smart ass but you know you can just get a vial of perservative free 0.25% bupivacaine and use that.

I know. That's what I use in my CSEs. I just liked that they had the sufenta pre-made up. It was stored where we had the bup/fent epidural bags.

 

[Planktonmd]

So... could someone explain to my aging brain what really was the issue here?
She has factor 5 leiden, she was on heparin but she is no longer anticoagulated since her PTT is now normal.
Why is this patient different than any other parturient concerning epidural analgesia or neuraxial anesthesia for BTL?

 

[deleted162650]

So... could someone explain to my aging brain what really was the issue here?
She has factor 5 leiden, she was on heparin but she is no longer anticoagulated since her PTT is now normal.
Why is this patient different than any other parturient concerning epidural analgesia or neuraxial anesthesia for BTL?

There's no issue. She's no different. Don't worry, your not (completely) senile yet.

 

[Scotty_G]

As a young attending I don't really understand the issue? FFL = hypercoaguable and if anticoag meds were stopped within timeframe what is the big deal? Spinal/epidural choose whichever you like with said resident skill level. With all due respect OP I think it's good you stayed in academics.

 

[deleted162650]

OP what's your set-up on call? How many residents or CRNA's are you supervising? How many ORs can you run in addition to OB?

 

[Planktonmd]

There's no issue. She's no different. Don't worry, your not (completely) senile yet.

Great... thank you for the reassurance!

 

[sigrhoillusion]

OP what's your set-up on call? How many residents or CRNA's are you supervising? How many ORs can you run in addition to OB?

It varies by the day. Sometimes it's 3 CRNAs, sometimes 2 CRNAs and a resident. Weekends it's 4 CRNAs, or 3 and 1. Usually running 2 rooms, with a 3rd person free. If a bad night with multiple level 1s then occasionally running 3. But it can vary, calls are hit or miss, usually you have something going on all night in one room, with an occasional second room. But after 9 or 10pm only level 1s can go if there's another level 1 going. They won't call in OR staff unless it's level 2 level 1s. If not constant, then you get an hour or two of sleep between cases. Then you're at the mercy of OB. I honestly don't mind traumas, I'll run them all night. Makes the call go by quickly. It's just when you're doing these things and then you gotta run over to OB to put an epidural in it's a PITA. Especially when they call you for multiple epidurals. And while you're doing those epidurals they call you for a level 1 trauma... Which is why having a resident as a buffer is so helpful.


But from what I've gathered, I appear to be a black cloud so far, which is the opposite of what I was in residency... haha.

 

[Planktonmd]

It varies by the day. Sometimes it's 3 CRNAs, sometimes 2 CRNAs and a resident. Weekends it's 4 CRNAs, or 3 and 1. Usually running 2 rooms, with a 3rd person free. If a bad night with multiple level 1s then occasionally running 3. But it can vary, calls are hit or miss, usually you have something going on all night in one room, with an occasional second room. But after 9 or 10pm only level 1s can go if there's another level 1 going. They won't call in OR staff unless it's level 2 level 1s. If not constant, then you get an hour or two of sleep between cases. Then you're at the mercy of OB. I honestly don't mind traumas, I'll run them all night. Makes the call go by quickly. It's just when you're doing these things and then you gotta run over to OB to put an epidural in it's a PITA. Especially when they call you for multiple epidurals. And while you're doing those epidurals they call you for a level 1 trauma... Which is why having a resident as a buffer is so helpful.


But from what I've gathered, I appear to be a black cloud so far, which is the opposite of what I was in residency... haha.

I hope you are getting paid enough for this abusive setup.

 

[sleepallday]

It varies by the day. Sometimes it's 3 CRNAs, sometimes 2 CRNAs and a resident. Weekends it's 4 CRNAs, or 3 and 1. Usually running 2 rooms, with a 3rd person free. If a bad night with multiple level 1s then occasionally running 3. But it can vary, calls are hit or miss, usually you have something going on all night in one room, with an occasional second room. But after 9 or 10pm only level 1s can go if there's another level 1 going. They won't call in OR staff unless it's level 2 level 1s. If not constant, then you get an hour or two of sleep between cases. Then you're at the mercy of OB. I honestly don't mind traumas, I'll run them all night. Makes the call go by quickly. It's just when you're doing these things and then you gotta run over to OB to put an epidural in it's a PITA. Especially when they call you for multiple epidurals. And while you're doing those epidurals they call you for a level 1 trauma... Which is why having a resident as a buffer is so helpful.


But from what I've gathered, I appear to be a black cloud so far, which is the opposite of what I was in residency... haha.

how many deliveries a year? Almost sounds like you need two attendings on call each night.

 

[deleted171991]

As a young attending I don't really understand the issue? FFL = hypercoaguable and if anticoag meds were stopped within timeframe what is the big deal? Spinal/epidural choose whichever you like with said resident skill level. With all due respect OP I think it's good you stayed in academics.

Oh, come on! He's 4 months out of fellowship, which was peds if I remember well. Of course he's not up to PP speed, especially if he does OB only on call, once in a while.

And this was a 4 am decision, which can be 21 hours awake. Not everybody is a genius at that hour.

 

[Planktonmd]

In private practice you don't need to be a genius, you just need to figure out your priorities and do your best not to get fired before you had built enough political credit.

 

[Scotty_G]

That is a rough night setup... How many night calls do you take? Please tell me you at least come in at 3 or 4PM for night call?

 

[Noyac]

.
But from what I've gathered, I appear to be a black cloud so far, which is the opposite of what I was in residency... haha.

Im Pretty sure that there is no such thing as a black cloud. At least not one that lasts any significant amount of time. The people who seems to have more bad calls than others are simply not managing their time and cases well.

Also, you have what I would consider a lot of support on call with residents and nurses. Why are you so reluctant to do cases? If you did this in my practice you would be sent packing because your mismanagement creates unnecessary additional work for the others.

You have 3-4 people after hours to do cases. Use them and bang out the cases. This sounds like a guy in my old practice that was so nervous of what "might" happen. We used to say that he keeps everyone around just in case a school bus full of hemophiliacs crashed.

 

[sigrhoillusion]

There's no issue. She's no different. Don't worry, your not (completely) senile yet.

On another side note, which I probably should have mentioned from the beginning. One of my attendings during residency had a patient with hypercoagulability state (think it was protein C) who developed a hematoma after epidural despite appropriate labs/mgmt of anti-coagulation. This was probably just bad luck and could have happened to any patient. She said despite being hypercoagable, the defect in coagulation

Im Pretty sure that there is no such thing as a black cloud. At least not one that lasts any significant amount of time. The people who seems to have more bad calls than others are simply not managing their time and cases well.

Also, you have what I would consider a lot of support on call with residents and nurses. Why are you so reluctant to do cases? If you did this in my practice you would be sent packing because your mismanagement creates unnecessary additional work for the others.

You have 3-4 people after hours to do cases. Use them and bang out the cases. This sounds like a guy in my old practice that was so nervous of what "might" happen. We used to say that he keeps everyone around just in case a school bus full of hemophiliacs crashed.

How am I reluctant to do cases? Because I don't think that doing an elective BTL at 4am is a good idea? Again we have 3 people available overnight, covering a large level 1 trauma center. I would run three rooms all night if I could, but usually it's the OR staff/nursing that prevents that. We do the cases we can, when we can. Any urgent cases get done. Any elective cases get bumped to the add-on list the next day. Again, they will not run any cases that aren't level 2 or higher overnight. If a level 1 is running, only another level 1 can go cause the OR staff refuses to call in the back up team. I've had numerous times where I've had 3-4 people at my disposable and have been unable to run more than 2 rooms. And did you miss the part where I said I usually push the staff to the limit often having nobody free in case something comes in? A few calls ago, I was board running, running 4 rooms, and OB so who was running to OB and the trauma bay? Me... So please don't question my ability to get things done and manage the staff. Soemtimes you're just dealt a bad hand.

Honestly, I think the 3-6pm part of the shift is the worst, cause having to juggle 3-4 rooms plus OB plus the board (and getting CRNAs and anesthesiologists out on time) can be a hassle. One time I some how gave myself 5 rooms for a few minutes before remembering outside cases... oops. I do my best to make my staff and the surgeons (and even OB...) happy. Me being cautious at 3-4am with a patient I wasn't 100% sure of shouldn't be a make or break it thing. Again, if she wasn't a mulitp at 7-8cm, I most likely would have done the epidural. But by the time I even decided to have her get a little pain medicine before I made a decision, the baby was out. Then the BTL wa a moot point, cause again, I'm not doing a BTL at 4am.

And to the otehr person, yes, I've only been there for 3 months but the rest of the group has been pushing for a seperate OB person for some time.

I said I agreed with SaltyDog, I have been alittle bit cautious in my first 3 months. Rather be safe than sorry. I especially feel this way in regards to OB, since I had been away from it for over a year with my fellowship. Also, where I trained I feel they were overly cautious with OB and even then I've already abandoned some of the things I was taught. Then again, I'd rather be dealing with a NEC baby at 3am with a ruptured AAA in another room, then deal with OB with nothing else running.... haha. To be fair though most of the surgeons here are reasonable and unless there's any urgency they know to reschedule cases as time goes on. They're most liklely to get bumped as more urgent/emergent things come in.

I used to question my attendings when they say you learn more in an attending your first year than you do in 3-4 years of residency, but there's definitely some truth to that. And to be honest, where I trained, the attending on call had it easy IMHO... Give me another month or two, and I'm pretty sure I'll open up a little. But If I'm still a scared little bitch, then you can teach me the ways of the force.

 

[Planktonmd]

On another side note, which I probably should have mentioned from the beginning. One of my attendings during residency had a patient with hypercoagulability state (think it was protein C) who developed a hematoma after epidural despite appropriate labs/mgmt of anti-coagulation. This was probably just bad luck and could have happened to any patient. She said despite being hypercoagable, the defect in coagulation

What does that mean?

 

[deleted162650]

It varies by the day. Sometimes it's 3 CRNAs, sometimes 2 CRNAs and a resident. Weekends it's 4 CRNAs, or 3 and 1. Usually running 2 rooms, with a 3rd person free. If a bad night with multiple level 1s then occasionally running 3. But it can vary, calls are hit or miss, usually you have something going on all night in one room, with an occasional second room. But after 9 or 10pm only level 1s can go if there's another level 1 going. They won't call in OR staff unless it's level 2 level 1s. If not constant, then you get an hour or two of sleep between cases. Then you're at the mercy of OB. I honestly don't mind traumas, I'll run them all night. Makes the call go by quickly. It's just when you're doing these things and then you gotta run over to OB to put an epidural in it's a PITA. Especially when they call you for multiple epidurals. And while you're doing those epidurals they call you for a level 1 trauma... Which is why having a resident as a buffer is so helpful.


But from what I've gathered, I appear to be a black cloud so far, which is the opposite of what I was in residency... haha.

Is this a small residency program you work at? I ask because it seems odd to me to have such a heavy CRNA presence on call with a relative lack of residents on call.

Call is where you earn your chops as a resident. The juniors get pushed doing cases that are outside their comfort zone, and the seniors get to spread their wings and fly under looser supervision. It's a shame those learning opportunities are being wasted on CRNA's.

When I was a resident, OB call went something like this:

3pm - check in with OB attending and relieve OB day resident. Clean up leftovers from day shift

7pm - OB call attending arrives. They say, "Hey what's the deck look like? . . .OK, cool. Let me know if there's a section. Otherwise, see ya in the morning."

 

[R-35]

What are your guys thoughts?

Last week I had a 22yo VERY NON-COMPLIANT patient with history of FVL present in labor. Patient was "seen" by MFM and heme-onc, sporadically. Her history of FVL included MULTIPLE blood clots including thrombotic events even during periods of compliance with anticoagulation. Per her notes in between clotting episodes she had been put on numerous meds including Lovenox and Xarelto. Back in 2015 she had in intracardiac thrombus which hwas usrgically removed after an IVC filter had been placed pre-op and subsequently removed later.

So now OB calls for epidural at 3am with the patient in labor at 7cm. Patient had two prior pregnancies which she delivered SVD without the use of epidural. but of course this one she was in too much pain and wanted one. Labs looked ok except for a slightly low PTT (24? don't remember exact number). Heranti-coag course this time was that she was bridged from Lovenox to 10,000units heprin TID at 36weeks. However, she stopped taking the heparing about a day before coming in labor. OB planning to restart anti-coagulation within 6 hours after delivery. And of course OB resident also mentions that patient desires BTL afterwards...

What would you guys do?

And before we get into too much debate, I told OB resident to give her fentanyl PCA. And of course 20 minutes later resident calls me back that patient delivered (probably before PCA was even started). Then she asked about the BTL and what our plan for that would be. Purely elective BTL at 4am... Would you guys spinal? GA? Tell them to come up with an anti-coag plan and get back to you?

There is no concern here for neuroaxial. More vigilance for perioperative DVT/PE for which she is at increased risk of.

Being in my first year of practice post fellowship in a public hospital, I can understand feeling anxious at times. Have references readily accessible, try to keep emotions out of your medical decision making. Get a second opinion if your torn between two defensible but difficult management options. You just finished residency all of your knowledge/high risk experience gained during residency should be fresh.

 

[deleted171991]

What does that mean?

I am not an expert in heme, but I know one thing for sure: PT, PTT, fibrinogen etc. don't always describe the coag picture properly. The one that comes closer to reality is TEG. That's the one I would trust in any hematologic disease.

Many coagulation disorders are not just one-sided. For example, cirrhotic patients with high INR can be actually coagulating just fine, because we are missing the decrease on the anticoagulant side, so despite a higher INR the anticoagulant/procoagulant balance in the blood is normal, maybe even tilted towards thrombosis.

I do realize that cirrhosis has a multifactorial effect on coagulation, due to the huge numbers of both pro- and anticoagulant factors synthesized by the liver. Still, the fact that this patient continued to thrombose on "therapeutic" levels of PTT, makes me think that the PTT does not fully describe her picture.

tl;dr: When faced with a non-trivial coagulation disorder, do a TEG. It's much closer to in vivo coagulation/fibrinolysis than any other blood test. Here's a brilliantly simple explanation of how it works (turn off the annoying music, watch at least the second half):

 

[Planktonmd]

I am not an expert in heme, but I know one thing for sure: PT, PTT, fibrinogen etc. don't always describe the coag picture properly. The one that comes closer to reality is TEG. That's the one I would trust in any hematologic disease.

Many coagulation disorders are not just one-sided. For example, cirrhotic patients with high INR can be actually coagulating just fine, because we are missing the decrease on the anticoagulant side, so despite a higher INR the anticoagulant/procoagulant balance in the blood is normal, maybe even tilted towards thrombosis.

I do realize that cirrhosis has a multifactorial effect on coagulation, due to the huge numbers of both pro- and anticoagulant factors synthesized by the liver. Still, the fact that this patient continued to thrombose on "therapeutic" levels of PTT, makes me think that the PTT does not fully describe her picture.

tl;dr: When faced with a non-trivial coagulation disorder, do a TEG. It's much closer to in vivo coagulation/fibrinolysis than any other blood test. Here's a brilliantly simple explanation of how it works (turn off the annoying music, watch at least the second half):

I understand that TEG is very helpful in many instances but it's not available everywhere, and factor 5 Leiden is the most common thrombophilic disorder (3-8 % of the white European population), it has no increased bleeding associated with it, and the pathophysiology is that factor five leiden cannot be deactivated as fast as normal factor five once a clotting process has started which increases clot formation.
Factor 5 Leiden is important to understand for anyone who practices OB anesthesia because of 2 issues:
1- The prophylactic anti coagulation the patient is receiving which affects the timing of neuraxial anesthesia or analgesia
2- The increased risk of clotting and thrombo-emboilc events in pregnant women who have the disorder
PTT is appropriate here simply to confirm that the Heparin is gone which is expected since the last dose was 24 hours ago.
The scenario the OP presented is a common one so it is important to have a preformulated understanding and plan to deal with it if one is to do OB anesthesia.

 

[deleted171991]

PTT was clearly enough to clear the patient for neuraxial anesthesia. The problem is, if the patient opts for elective laparoscopic (not open) BTL, this patient was hypercoagulable even at a therapeutic PTT (not to speak of her current low-normal one) and will have increased risk of thrombosis with GA, so actually she does need to be optimized for surgery from anticoagulation standpoint (by a hematologist), and the best way to do it is to also involve TEG (to bring her to a sweet spot where she is clotting exactly as much as needed for her surgery). Even if the BTL is open, that will probably delay anticoagulating the patient properly postop, but that's mostly the surgeon's problem.

I find it funny that people are usually so concerned about thrombosing a cardiac stent, but they are not concerned about the risk of a PE in a young person.

We are not in Scandinavia in 1970. There is no urgency in sterilizing this patient "for social benefit", before she leaves the hospital.

 

[Planktonmd]

We are not in Scandinavia in 1970. There is no urgency in sterilizing this patient "for social benefit", before she leaves the hospital.

Don't you sometimes wish there was such a thing as emergency sterilization?

 

[fakin' the funk]

Ok, for starters, when the OB presented the idea of doing a BTL at 0400, you should have asked her how she managed to park her short bus in the physician lot.

Ohhh, SASSY!

 

[fakin' the funk]

Purely elective BTL at 4am... Would you guys spinal? GA? Tell them to come up with an anti-coag plan and get back to you?

You said it. It's elective. You tell em GTFOH