OB Case

[RussianJoo]

I do quite a bit of OB calls and had this come up a few times. The attendings in my group are mixed in their management of this situation, so maybe some of you OB experts can help.

Here's the situation: Laboring patient comes into the hospital and for one reason or another needs an urgent C-section. The problem is she had a full meal (McDonalds or a steak) a few hours prior to this. The OB wants to do the case under a spinal. I tell them no, the patient is not NPO and if we're going now, she's going to sleep with an ET tube. My rational is that this is an urgent/emergent case, full stomach, I must secure the airway. Some of my colleagues argue that they would do the spinal, the patient is wide awake, her gag reflex is intact so if she does vomit she won't aspirate.

How would you do these types of cases? General or Wide awake and spinal?

If something bad happens and you get sued can you really defend yourself by not securing the airway on a full stomach patient?

Your thoughts appreciated.

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[Planktonmd]

A pregnant woman is always full stomach so it does not matter... do a spinal and move on

 

[Arch Guillotti]

I do quite a bit of OB calls and had this come up a few times. The attendings in my group are mixed in their management of this situation, so maybe some of you OB experts can help.

Here's the situation: Laboring patient comes into the hospital and for one reason or another needs an urgent C-section. The problem is she had a full meal (McDonalds or a steak) a few hours prior to this. The OB wants to do the case under a spinal. I tell them no, the patient is not NPO and if we're going now, she's going to sleep with an ET tube. My rational is that this is an urgent/emergent case, full stomach, I must secure the airway. Some of my colleagues argue that they would do the spinal, the patient is wide awake, her gag reflex is intact so if she does vomit she won't aspirate.

How would you do these types of cases? General or Wide awake and spinal?

If something bad happens and you get sued can you really defend yourself by not securing the airway on a full stomach patient?

Your thoughts appreciated.

I would do the case under spinal whenever close to 100% of the time. GETA only under emergency circumstances and certainly never under the scenario you are describing.

 

[Arch Guillotti]

The OB wants to do the case under a spinal. I tell them no, the patient is not NPO and if we're going now, she's going to sleep with an ET tube. My rational is that this is an urgent/emergent case, full stomach, I must secure the airway.

This is dogmatic and I think in a few years you will realize so.

 

[somedumbDO]

As much as I want to say prop/sux/tube. Just do spinal and call it a day.

 

[Timeoutofmind]

Serious?

Bro...it's a spinal.

For the residents though:

By your logic, regional anesthesia is never acceptable in a full stomach situation. Why? "in case something goes bad and the airway is not secured".

?

Not a logical thought process. Just to spell the error in reasoning out:

You are going to expose this patient to the HIGH risk of aspiration associated with an elective RSI/full stomach induction...in order to avoid the VERY LOW risk of "something bad" happening intraop while the airway is unsecured, and the further additional LOW probability event that must also occur that you cannot rapidly secure the airway with an emergent RSI?

And: maternal changes associated with pregnancy making far more difficult airway's (e.g. Now you have decided to electively RSI and cannot and now mom aspirated, fetal hypoxia, etc.) Or consider that you are exposing the fetus to drugs, and all the other problems with GA in a term patient also need to be taken into consideration as well…

 

[Arch Guillotti]

You are going to expose this patient to the HIGH risk of aspiration associated with an elective RSI/full stomach induction...in order to avoid the VERY LOW risk of "something bad" happening intraop while the airway is unsecured, and the further additional LOW probability event that must also occur that you cannot rapidly secure the airway with an emergent RSI?

I would argue that the chances of an aspiration are incredibly low. I agree with your sentiment though.

 

[drmwvr]

Every single aspiration I personally have been involved with directly or indirectly, without exception, has involved induction of general anesthesia.

 

[pgg]

I'm surprised you wanted to intubate her. Let me ask you this -

If this woman who got a McSteak a few hours prior asked you for a labor epidural, would you place one? Of course you would. And it would work great.

If an hour later the OB called a section - not emergent, but not something that could be delayed 4 hours - would you put her to sleep? I'd hope not.

 

[BLADEMDA]

I do quite a bit of OB calls and had this come up a few times. The attendings in my group are mixed in their management of this situation, so maybe some of you OB experts can help.

Here's the situation: Laboring patient comes into the hospital and for one reason or another needs an urgent C-section. The problem is she had a full meal (McDonalds or a steak) a few hours prior to this. The OB wants to do the case under a spinal. I tell them no, the patient is not NPO and if we're going now, she's going to sleep with an ET tube. My rational is that this is an urgent/emergent case, full stomach, I must secure the airway. Some of my colleagues argue that they would do the spinal, the patient is wide awake, her gag reflex is intact so if she does vomit she won't aspirate.

How would you do these types of cases? General or Wide awake and spinal?

If something bad happens and you get sued can you really defend yourself by not securing the airway on a full stomach patient?

Your thoughts appreciated.

I know you are a fairly new attending and a regular on SDN for many years. If something "bad happens" it will because you chose to do a General anesthetic over a Spinal/SAB because of a false concern over NPO. All Pregnant patients are full stomachs and should be treated as such. That said, if the OB agrees to wait 4-5 hours before doing a C section on these patients I often go down that path. Again, the technique of choice is a Neuraxial one without any sedation.

I'm sure you will read these posts and adjust your practice going forward. Best of luck.

 

[GravelRider]

Pregnant women vomit during c-section with a spinal all the time...whether they were NPO or not. Do a spinal and make her husband hold the vomit basin.

 

[2ndyear]

Every single aspiration I personally have been involved with directly or indirectly, without exception, has involved induction of general anesthesia.

Yes, but didn't the most recent OB closed claims show by far the majority of aspiration in OB actually happens on extubation?

 

[PainDrain]

Yes, but didn't the most recent OB closed claims show by far the majority of aspiration in OB actually happens on extubation?

I believe it shows that the majority of maternal deaths were due to lost airway leading to hypoxia and death on extubation.

 

[partydoc]

spinal

 

[MBZMD]

New-ish attending here too (< 5 years) but dont understand your logic. Spinal almost 100% of the time for any C/S. Especially if not NPO.

 

[Scotty_G]

Yes should be no question about GA vs spinal. Looks like you still have a little academia in you

 

[lakersbaby]

If I were that OB I would be pretty pissed and probably call your chief about it. I just don't see the rationale at all here. The spinal is a gift in this situation. Worst case scenario you prepare for a GA, put in a spinal and be ready for an RSI if need be. I'm sure you've gotten the point now tho with all these responses. You must be more flexible especially in the private world.

 

[RussianJoo]

Thanks everyone.. Lapse of judgment at 3am on m part. Definitely won't happen again.

 

[urge]

Spinal.


Another one not making partner.

 

[pgg]

Another one not making partner.

No need to be a dick.

Everyone does things early out of residency they later do differently. It doesn't help that academia has some truly excessively conservative and dogmatic teachers who hammer residents for doing safe things the PP world does every day. Right now I still consider myself new and learning 7 years out, but when I was very new I put off a couple cases I shouldn't have, had subsequent uncomfortable conversations where I was corrected, and got better. You can find a couple of my screwup threads here someplace ...

Overcautious errors are far better than the other kind. I'd rather a new colleague be conservative than cowboyish.

And for godsake let's not give people **** for posting their learning experiences or errors here.

 

[deepstate2016]

Well I agree a spinal would be fine, preferable, and the move outside of the ivory tower. In the defence of the OP is two fold.
1. He is like the rest of us learning, thanks gov for pointing that out. The day we stop learning and growing is the day we die.
2. There may be information that was not given in the original report that would influence the decision.

 

[deepstate2016]

Oh and third since when does surgeon preference trump our judgement? OB says gotta go OK they are the baby expert, I am not going to second guess them, we are the anesthesia experts. If they get the urge to double board in anesthesia and obstetrics hurray! Until then grab a big cup of sit down and shut up.

 

[deleted162650]

This may mark the first time in SDN Anes history that everyone agrees.

A pregnant woman is always full stomach so it does not matter

People need to stop saying this. It isn't true. A laboring woman is always a full stomach. Pregnancy does not change gastric emptying - labor does (and markedly so). A fasted pregnant woman is just as fasted as a non-pregnant woman (barring any other comorbid contributing factors).

Think about all the scheduled NPO sections you've done where mom gets a little pukey. What do they barf up - just some bile and the bicitra the nurse gave 'em even though you told her not too. I've never seen the previous nights dinner come up - have you?

 

[urge]

No need to be a dick.

Everyone does things early out of residency they later do differently. It doesn't help that academia has some truly excessively conservative and dogmatic teachers who hammer residents for doing safe things the PP world does every day. Right now I still consider myself new and learning 7 years out, but when I was very new I put off a couple cases I shouldn't have, had subsequent uncomfortable conversations where I was corrected, and got better. You can find a couple of my screwup threads here someplace ...

Overcautious errors are far better than the other kind. I'd rather a new colleague be conservative than cowboyish.

And for godsake let's not give people **** for posting their learning experiences or errors here.

Millennials...

 

[pgg]

Millennials...

I'm an X'er, and I'm entitled to more respect than millenials!

 

[deleted162650]

Millennials...

Get off my lawn Boomer!

 

[Planktonmd]

This may mark the first time in SDN Anes history that everyone agrees.



People need to stop saying this. It isn't true. A laboring woman is always a full stomach. Pregnancy does not change gastric emptying - labor does (and markedly so). A fasted pregnant woman is just as fasted as a non-pregnant woman (barring any other comorbid contributing factors).

Think about all the scheduled NPO sections you've done where mom gets a little pukey. What do they barf up - just some bile and the bicitra the nurse gave 'em even though you told her not too. I've never seen the previous nights dinner come up - have you?

I think you are missing the meaning of what I said!!!
When we say "pregnant women are always full stomach", it doesn't mean that they actually have a stomach full of food all the time, it means that whenever you induce general anesthesia on a pregnant woman you are expected by the Gods of anesthesia to do a rapid sequence induction or you would be in violation of one of the holiest doctrines and you could be very easily excommunicated!
So calm down and don't get your panties in a wad!

 

[deleted162650]

I think you are missing the meaning of what I said!!!
When we say "pregnant women are always full stomach", it doesn't mean that they actually have a stomach full of food all the time, it means that whenever you induce general anesthesia on a pregnant woman you are expected by the Gods of anesthesia to do a rapid sequence induction or you would be in violation of one of the holiest doctrines and you could be very easily excommunicated!
So calm down and don't get your panties in a wad!

My panties are not in a wad - it's hard to wad a thong .

It's just that this is a piece of dogma that gets repeated continually, and I thought the majority of us here were anti-dogma.

 

[Planktonmd]

My panties are not in a wad - it's hard to wad a thong .

It's just that this is a piece of dogma that gets repeated continually, and I thought the majority of us here were anti-dogma.

Well... it is dogma and most likely BS, but most practicing anesthesiologists will tell you that a pregnant woman = rapid sequence, because that's what they were taught!

 

[urge]

My panties are not in a wad - it's hard to wad a thong .

Millennials....

 

[BLADEMDA]

Can J Anaesth. 2012 Jul;59(7):648-54. doi: 10.1007/s12630-012-9718-4. Epub 2012 May 4.
The LMA Supreme™ in 700 parturients undergoing Cesarean delivery: an observational study.
Yao WY1, Li SY, Sng BL, Lim Y, Sia AT.
Author information

• 1Department of Anesthesia, Quanzhou Women's and Children's Hospital, Fujian, China.

Abstract
BACKGROUND:
The LMA Supreme™ (SLMA) is a single-use supraglottic device that provides a good seal for positive pressure ventilation. It has a double aperture design that facilitates the introduction of an orogastric tube to aspirate gastric contents. This observational study evaluated the role of the SLMA in parturients undergoing Cesarean delivery under general anesthesia.

METHODS:
Non-obese parturients with at least four hours of fasting and antacid prophylaxis scheduled for uncomplicated Cesarean delivery were recruited from June 2009 through May 2010 at the Quanzhou Women's and Children's Hospital, China. We recorded the number of SLMA insertion attempts, the time to effective ventilation, the incidence of aspiration, and other anesthetic and obstetric outcomes. Postoperatively, we noted the presence of blood on the SLMA, postoperative sore throat, and patient satisfaction. Analysis included comparison of results between parturients having elective and urgent Cesarean delivery.

RESULTS:
We recruited 700 parturients (576 elective, 124 urgent). Mean (standard deviation) body mass index was 25.6 (2.5) kg·m(-2). All SLMA insertions were successful, with 686 (98%) inserted on first attempt and a time to effective airway of 19.5 (3.9) sec. We maintained ventilation and oxygenation in all parturients with a good seal and there was no evidence of aspiration. Eighteen parturients (2.6%) had blood on the SLMA upon removal, 24 (3.4%) had sore throat, and patient satisfaction was 85 (7)%. These results were similar in elective and urgent cases.

CONCLUSIONS:
In a carefully selected group of parturients, the SLMA is a useful alternative to tracheal intubation for Cesarean delivery, providing effective ventilation and a low incidence of side effects or complications.

 

[deleted162650]

I'm an X'er, and I'm entitled to more respect than millenials!

I thought X'ers were too lazy and apathetic to be entitled??

 

[BLADEMDA]

Do many of you keep a Glidescope/McGrath/C-Mac in the OB suite? Or, is the LMA the de-facto choice if you can't intubate a patient about to get a C-Section?

 

[vector2]

Do many of you keep a Glidescope/McGrath/C-Mac in the OB suite? Or, is the LMA the de-facto choice if you can't intubate a patient about to get a C-Section?

we keep a glide, mcgrath, and bronch tower in the ob supply room.

 

[Ezekiel2517]

Do many of you keep a Glidescope/McGrath/C-Mac in the OB suite? Or, is the LMA the de-facto choice if you can't intubate a patient about to get a C-Section?

Glide in the room. But it's so rare I have to go GA in OB.
To the new grads: OB nurses are pretty clueless about GETA in the OR, so be extra prepared. True story: a colleague of mine had to induce GA for an emergent CS. Succ isn't kept in the drawer in the OB cart so he yelled to the RN that he needs it. RN came back and gave him a pair of hospital socks still in the plastic bag.

 

[confusingleaf]

Glide in the room. But it's so rare I have to go GA in OB.
To the new grads: OB nurses are pretty clueless about GETA in the OR, so be extra prepared. True story: a colleague of mine had to induce GA for an emergent CS. Succ isn't kept in the drawer in the OB cart so he yelled to the RN that he needs it. RN came back and gave him a pair of hospital socks still in the plastic bag.

i really wish that surprised me

 

[2Fast2Des]

Glide in the room. But it's so rare I have to go GA in OB.
To the new grads: OB nurses are pretty clueless about GETA in the OR, so be extra prepared. True story: a colleague of mine had to induce GA for an emergent CS. Succ isn't kept in the drawer in the OB cart so he yelled to the RN that he needs it. RN came back and gave him a pair of hospital socks still in the plastic bag.

I was part of a case where probably 6 people (OB nurses) standing around pt yelling and slapping mom's arms to wake up and breathe while she was taking a bit longer to emerge after getting reversal in the OR, that was a great scene to witness.

What is your guys' thought on aspiration prophylaxis for elective C/S and in that case, emergent ones as well? What regimen is better or not effective?

 

[PainDrain]

Spinal.


Another one not making partner.

So as a fairly new grad (4 yrs) I was cautious at first also. I feel part of becoming a new attending is learning the culture of being an attending in your current practice. I kept looking at what others around were doing and what I was taught in residency. I felt my OB experience in residency was superb and we had a lot of attendings who practiced like most would in private practice. That being said they were appropriately cautious in certain situations and I felt like some of the stuff I have seen in the community setting is bordering on gross negligence (I have written before about OB patients on here). I have seen patients with pre-pregnancy BMIs >50 who are delivering at a community hospital, VBACs after two sections, congenital anomaly patients, elective sections on complicated patients at 10pm with no staff, ect. Part of the issue I have seen is the anesthesiologists at this place have let the OBs get away with this bull**** for so long it's become second nature. I personally had it out with a few OBs who were downright dangerous. Don't be afraid to stand your ground if you feel it's a dangerous situation.

I agree with those above though. If it has to immediately go to section then it's a spinal all the way.

 

[Planktonmd]

So as a fairly new grad (4 yrs) I was cautious at first also. I feel part of becoming a new attending is learning the culture of being an attending in your current practice. I kept looking at what others around were doing and what I was taught in residency. I felt my OB experience in residency was superb and we had a lot of attendings who practiced like most would in private practice. That being said they were appropriately cautious in certain situations and I felt like some of the stuff I have seen in the community setting is bordering on gross negligence (I have written before about OB patients on here). I have seen patients with pre-pregnancy BMIs >50 who are delivering at a community hospital, VBACs after two sections, congenital anomaly patients, elective sections on complicated patients at 10pm with no staff, ect. Part of the issue I have seen is the anesthesiologists at this place have let the OBs get away with this bull**** for so long it's become second nature. I personally had it out with a few OBs who were downright dangerous. Don't be afraid to stand your ground if you feel it's a dangerous situation.

I agree with those above though. If it has to immediately go to section then it's a spinal all the way.

In the current market environment you can't afford to be a dick in private practice, you have to play ball and you have to earn the political credit you need before you start fighting with surgeons and cancelling cases.
You should be able to do things under sub optimal conditions and do them safely, if you can't do that then you belong in academia.

 

[Planktonmd]

I was part of a case where probably 6 people (OB nurses) standing around pt yelling and slapping mom's arms to wake up and breathe while she was taking a bit longer to emerge after getting reversal in the OR, that was a great scene to witness.

What is your guys' thought on aspiration prophylaxis for elective C/S and in that case, emergent ones as well? What regimen is better or not effective?

The best regimen is give nothing! Bicitra makes them vomit, Reglan causes extrapyramidal syndrome and it doesn't work, H2 inhibitors don't work unless given early.

 

[PainDrain]

In the current market environment you can't afford to be a dick in private practice, you have to play ball and you have to earn the political credit you need before you start fighting with surgeons and cancelling cases.
You should be able to do things under sub optimal conditions and do them safely, if you can't do that then you belong in academia.

While I agree with the above, don't ever place your patient (better yet yourself) in a dangerous situation simply because you want to make partner someplace. It isn't going to go well long term if you become a "yes man" because eventually you get burned.

 

[Noyac]

While I agree with the above, don't ever place your patient (better yet yourself) in a dangerous situation simply because you want to make partner someplace. It isn't going to go well long term if you become a "yes man" because eventually you get burned.

Possibly but we as ANESTHESIOLOGISTS need to learn how to get our pts through anything and many times it's not their pathology alone but it's also a poor surgeon or poor decisions made by others in the pts care. You must be able to do many things very well. In other words you can't be a one trick pony. If you are a young physician sometimes you need to step outside of your comfort zone. Baby steps maybe but pay attention to what the more respected partners are doing and figure out why and how to do it. Once you become one of those respected doc's then you can put your foot down more easily and others will just give way to your superiority.
ALSO, I really feel that doing a GA is way more risky in this situation than a SAB as others have said.

 

[deleted171991]

While I agree with the above, don't ever place your patient (better yet yourself) in a dangerous situation simply because you want to make partner someplace. It isn't going to go well long term if you become a "yes man" because eventually you get burned.

In a place where everybody bends over backwards for surgeons, if you don't play the Russian roulette, you'll be deemed as an obstructionist and/or incompetent. This is a question that should be addressed while interviewing for a job. A good group should have clear, well-advertised, non-exclusive criteria for cancelling cases, no exceptions allowed. As in: if the policy says blood sugar over 300 gets cancelled, then it gets cancelled for everybody, every time, no debates.

 

[fakin' the funk]

Agreed. Making fun of people for being on the conservative side is a nurse move.

He's not being made fun of for being conservative, he's being made fun of for not thinking.

 

[fakin' the funk]

My rational is that this is an urgent/emergent case, full stomach, I must secure the airway.

Why? You ever seen an awake, unsedated, neurologically intact person aspirate? The airway in an awake parturient IS secured, via resting muscle tone and intact gag/cough afferents+efferents.

 

[fakin' the funk]

I must secure the airway

"There is a fracture, I must fix it"

 

[SitraAchra]

Why? You ever seen an awake, unsedated, neurologically intact person aspirate? The airway in an awake parturient IS secured, via resting muscle tone and intact gag/cough afferents+efferents.

You seem like a peach. I'm sure your colleagues agree.

 

[GravelRider]

"There is a fracture, I must fix it"

I don't blame the OP from asking the question. The vast majority of what we know about NPO guidelines and aspiration risk is based on crummy studies and historical ignorance. Plus we get a lot of mixed messages about aspiration risk and full stomach from attendings in residency and senior guys in practice.

The senior partner in my cr@ppy practice delayed a case for 8 hours the other day because the patient was chewing gum. This fake anesthesiologist has supposedly has been practicing for 30 years. The real reason he delayed the case was it allowed him to go home and dump it on one of the worker bees, but that's another story...

 

[Planktonmd]

The senior partner in my cr@ppy practice delayed a case for 8 hours the other day because the patient was chewing gum. This fake anesthesiologist has supposedly has been practicing for 30 years. The real reason he delayed the case was it allowed him to go home and dump it on one of the worker bees, but that's another story...

This is a common situation in most private groups that have not yet been taken by AMCs.
They all have a couple of older guys who control the money and screw the new guys at every occasion.

 

[deleted171991]

You seem like a peach. I'm sure your colleagues agree.

I'm even more charming in real life.

I disagree with @RussianJoo here (how courageous of me), but I think everybody should be allowed to do cases in whatever way they feel comfortable with, including not doing them at all. We all have our limits and, while pushing limits is occasionally recommended, it's also risky and stressful. And a stressed anesthesiologist is just a disaster waiting to happen.

I used to work in an academic group where some people would put in ETTs for many cases I used LMAs in, or would put in LMAs for short cases I did with only a nasal cannula and chin lift. As long as the patient is unharmed, who am I to say which one is the right way? Even if it takes 10 minutes longer, it's worth having a relaxed person at the head of the bed.