Theoretical Scenario - OB Anesthesia

[hiyaman]

You have a patient laboring on the OB floor. She is pre-eclamptic and has multiple signs of difficult airway management. I.e. inter-incisor distance is small, micrognathia etc. You place an epidural for labor analgesia. She ends up needing stat C-section due to fetal bradycardia and decelerations. You end up using the epidural but its miraculously no longer working and there is no time for a spinal. They can't get fetal heart tones.

In this case would you

A. Attempt awake fiberoptic intubation
B. Induce and hope you can intubate
C. Mask down and keep spontaneously breathing in order to get case started and then manage airway with fiberoptic
D. Other alternative?

I was perusing the ASA statement for practice guidelines for OB as well as the difficult airway society OB guideline (UK I believe) and it was unclear to me if you had an emergent OB scenario due to fetal well being but mother was at high risk for failed airway and thus at high risk for morbidity whether you should proceed.

What would you all do?

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[Twiggidy]

We have glidescopes and an airway cart outside the OB OR. I'd put the patient to sleep and proceed down the airway algorithm.

 

[Volatile]

It’s been a few years since I took oral boards, but I think the board answer is if you are truly worried about the airway the mothers life trumps the fetus and the answer is an awake intubation. In actuality, I think it is exceedingly rare to lose the airway with all of our adjuncts. We have a glidescope in every OB room and a fiber optic outside the OB OR’s. I would likely RSI and plan for VL while having fiber optic brought into room if needed.

 

[UnbentLaryngoscope]

Ketamine induction to maintain spontaneous breathing, glidescope for first intubation attempt. Emergency airway equipment on standby. Difficult airway algorithm from there. Realize that if you're in a really tough spot, you can to a GA c-section with an LMA, acknowledging that doing so is suboptimal.

Tell the OB that as soon as the patient is asleep, they should cut, don't wait for the airway to be secured because that might be a while if the patient is really difficult. Remind them that the whole point of all these shenanigans is to get the baby out before it's dead.

If the patient really looked like they had a bad airway when you originally met them to place their epidural, ideally she was counseled regarding the various bad outcomes she might experience in the event of an emergency GA.

 

[GassYous]

Mother is the patient. But I would sleep her, let them section and try to figure out the airway. Mcgrath should do the trick. Unless she had radiation to the neck or something I would rsi and intubate due to risk of aspiration even though I think that risk is low. Help in the room, difficult airway cart, etc.

 

[MirrorTodd]

I'd tell the OB's to get a crich kit and keep a scalpel in hand.

 

[GassYous]

I'd tell the OB's to get a crich kit and keep a scalpel in hand.

TBH I'd rather crich myself

 

[Arch Guillotti]

I'd tell the OB's to get a crich kit and keep a scalpel in hand.

Not sure if srs

 

[MirrorTodd]

Not sure if srs

Lol not serious, sometimes it's fun to scare the OB's.

 

[pgg]

Not sure if srs

It's more plausible than "do the section under local"

 

[jwk]

It's more plausible than "do the section under local"

It’s doable. It ain’t fun at all - but it’s doable.

 

[Twiggidy]

I honestly think I'd shove an LMA in someone before I made the OBs do a section under local

 

[NitroS]

Doing a csection under local is how you get patients to sue you

Mom-to-be was given C-section without anesthesia, according to lawsuit

When a woman needed an emergency caesarean section at an Oceanside hospital last year, the anesthesiologist could not be quickly found — so the surgery was done without anesthesia, according to the woman, her fiance and their lawsuit.

www.latimes.com

 

[Arch Guillotti]

Go old school. Blind nasal intubation. Scrounge up a whistle and put it on the end of the tube if you want.

 

[gcc322]

If you have time to do an awake FOI you have time to do a spinal.

 

[woopedazz]

Ketamine induction to maintain spontaneous breathing, glidescope for first intubation attempt. Emergency airway equipment on standby. Difficult airway algorithm from there. Realize that if you're in a really tough spot, you can to a GA c-section with an LMA, acknowledging that doing so is suboptimal.

Tell the OB that as soon as the patient is asleep, they should cut, don't wait for the airway to be secured because that might be a while if the patient is really difficult. Remind them that the whole point of all these shenanigans is to get the baby out before it's dead.

If the patient really looked like they had a bad airway when you originally met them to place their epidural, ideally she was counseled regarding the various bad outcomes she might experience in the event of an emergency GA.

Is your plan A really a ketamined, unparalised, labouring patient; getting cut open and potentially delivering by a panicky OBS as your trying to get your first view?

What you got up your sleeve for plan B?

 

[IMGASMD]

Lol not serious, sometimes it's fun to scare the OB's.

Reminds me of a “consult” I got for an actively withdrawal laboring patient, who has no peripheral veins. The consult was to place a central line, so patient can get fluid before epidural….
I like the this particular ob, little nutty, little crazy. I was on call, no other cases…. Sure, why not.
While I was getting this line done, she was recount her glory days twenty years ago, when she was the **** placing central lines, left and right.

If place a triple lumen, was the highlight of your procedural prowess, the chance of an ob doing a trach is on par as me doing a cataract extraction…. (I was on eyeball duty today….)

 

[IMGASMD]

I’ve always been taught a “true” unable to intubate and unable to ventilate patient is rare to find. Don’t know the real percentage, but I do “generally” find it to be true.

I would preoxygenate as much as I can, prop, sux, glidescope. If unable to intubate, then try ventilate with an oral/nasal airway, and go down the other pathway….. LMA has bailed me out a few times, two hand ventilation has bailed me out a few times. They “should” have the baby out by now and the patient “should” return to breathing soon. More time to think what to do next, contemplating what’s the meaning of life and why the **** did I take John’s call on L&D today?

Sure the chance of aspiration in a full stomach pregnant patient is higher than other healthy patients, but if that fetus is not out within 5 mins, while I am doing an awake intubation?! I am sure I will be named in the suit one way or another.

 

[ryanjmy]

multiple signs of difficult airway management. I.e. inter-incisor distance is small, micrognathia etc.

To break out the bronchoscope I’m going to need to see a >10 cm mass distorting the airway. What you describe is a standard glide scope situation.

 

[hiyaman]

awesome, thanks for the responses. I guess I just wanted to see what most people thought about making the decision to go to sleep in the first place. I think once you're asleep and you have difficulty with airway management you go down the difficult airway algo for OB etc. But I just did not see much guidance on the initial decision in a scenario where its high morbidity/mortality for baby if you don't deliver immediately vs. high morbidity/mortality to mother if you do induce.

And I understand this scenario is very rare. But just something I was thinking about randomly and tried to find something regarding it and realized there was not a ton (unless I missed something).

 

[dannyboy1]

Put her to sleep. You will be able to intubate her with video. The odds that she will be the patient that is impossible to intubate and also impossible to ventilate is next to zero. In fact I have yet to see or hear of the patient who cannot be ventilated with two hands, oral airway and paralysis. I’m sure it exists but it ain’t gonna be her

 

[Twiggidy]

As a side note, I think timing of her labor induction is also important. I would be up in arms if an OB had most of this drama timed to occur overnight versus during the day when more friends are around to help. I understand OB isn't 9-5 but I'd be a little angry and may have a department discussion if they were starting her pitocin at 11pm vs 7am. If this patient walks in 7 cm ruptured in labor then "stuff happens".

 

[GassYous]

As a side note, I think timing of her labor induction is also important. I would be up in arms if an OB had most of this drama timed to occur overnight versus during the day when more friends are around to help. I understand OB isn't 9-5 but I'd be a little angry and may have a department discussion if they were starting her pitocin at 11pm vs 7am. If this patient walks in 7 cm ruptured in labor then "stuff happens".

The overnight pit thing drives me nuts. Why can't they start it at a normal time like normal people

 

[nimbus]

The overnight pit thing drives me nuts. Why can't they start it at a normal time like normal people

Office

 

[IMGASMD]

The overnight pit thing drives me nuts. Why can't they start it at a normal time like normal people

Normal people and L&D are two things that don’t go together.

 

[Twiggidy]

Normal people and L&D are two things that don’t go together.

Exactly

 

[IMGASMD]

Exactly

I general enjoy l&d.

In training, I’ve never understood why our attendings were so curt with the staff there…. Until I become an attending.

I will say this though, if I have the choice of covering L&D solo or covering crna in the general OR. L&D still wins every single time.

 

[UnbentLaryngoscope]

Is your plan A really a ketamined, unparalised, labouring patient; getting cut open and potentially delivering by a panicky OBS as your trying to get your first view?

What you got up your sleeve for plan B?

Yup, that's plan A. It's totally doable to get a view with a glidescope with ketamine without paralysis. Once the patient is induced and the Glidescope is in the mouth you'll have a lot more information than you had when you started to inform your next move.
--I actually have a good view, great! Give sux and intubate. Pat self on the back
--I have a really bad view, but good enough to still get the airway with a Bougie. Do that.
--I see nothing, boy I'm glad the patient is still spontaneously breathing. Put in an intubating LMA and turn on the gas. Prepare for fiberoptic.

That's kinda how I have it in my head anyway.

 

[GassYous]

Yup, that's plan A. It's totally doable to get a view with a glidescope with ketamine without paralysis. Once the patient is induced and the Glidescope is in the mouth you'll have a lot more information than you had when you started to inform your next move.
--I actually have a good view, great! Give sux and intubate. Pat self on the back
--I have a really bad view, but good enough to still get the airway with a Bougie. Do that.
--I see nothing, boy I'm glad the patient is still spontaneously breathing. Put in an intubating LMA and turn on the gas. Prepare for fiberoptic.

That's kinda how I have it in my head anyway.

Have you ever done 3?

 

[UnbentLaryngoscope]

Have you ever done 3?

I have had to go down path #3 exactly once. That occasion was not for a c-section however.

 

[Mman]

Office

the private OBs I work with have no problem doing their failure to progress csections during normal hours (say 7 AM to 9 PM). Almost never after midnight.

 

[Planktonmd]

Induce GA and give the intubation a shot with a videoscope, if not successful on the first attempt place an LMA and do the C section just with LMA.
The worst thing you can do here is continue to screw around with the airway.

 

[Angus Avagadro]

Go old school. Blind nasal intubation. Scrounge up a whistle and put it on the end of the tube if you want.

I wouldn't do that. Nasal passages are swollen from progesterone. Stuffy Nose of pregnancy. No time to shrink the nasal passages. You will see blood spurting out of the nose and down the back of the throat like you have never seen before. I like RSI better with glide and airway cart. Given the choice, OP didn't say the patient was morbidly obese or had Harrington Rods the length of her spine, so I would probably go with spinal as first choice.. This situation generally sucks. I have seen one section done under local,(actually didn't) . They were delivering the placenta when I arrived. It was at a small country hospital where the OBs were pretty slick. Big city OBs would unlikely be skilful enough to do it under local.

 

[Greenbayslacker]

RSI Glidescope, LMA/mask backup. A good OB would have the baby out before you even have all your FOB equipment ready to go

 

[MirrorTodd]

RSI Glidescope, LMA/mask backup. A good OB would have the baby out before you even have all your FOB equipment ready to go

Hell even a bad one will, the pt will just end up with a **** ton of blood loss and a lopsided scar.

 

[fakin' the funk]

If it was simply late decels, I'd tell the surgeon I was doing a spinal whilst fetus is being monitored. Takes 2 mins tops. Or an awake fiberoptic if it HAD to be done under GA. If they give pushback I'd tell them they can perform it under local only then. My board certification = my rules.

It's not SDN Anesthesia without the insane, unrealistic-numbers, macho bravado stuff.

(Btw I can do a spinal in 119 seconds so eat it)

 

[FiO2@21]

It's not SDN Anesthesia without the insane, unrealistic-numbers, macho bravado stuff.

(Btw I can do a spinal in 119 seconds so eat it)

The ones who do 100% OB probably get close to those numbers

 

[GassYous]

It's not SDN Anesthesia without the insane, unrealistic-numbers, macho bravado stuff.

(Btw I can do a spinal in 119 seconds so eat it)

I don't think it's insane. During residency I had an attending pop in a spinal in an emergent case in what felt like 30 seconds but was probably under 2 minutes

 

[pgg]

The ones who do 100% OB probably get close to those numbers

We can all do procedures lightning fast, most of the time. 2 minutes for a spinal isn't outrageous. But anyone who says they can pop in an OB spinal in 2 minutes (kit-opening to lay-her-down) 100% of the time, or even 80% of the time, is delusional or simply mistaken.

Especially in an emergent c-section when the people around you and the patient are in freakout mode.

And that's the problem. Even if you can objectively do it in 2 minutes 85% of the time, are you willing to risk that 15% when you DON'T do it in 2 minutes, and then have to go to plan B, when baby brain cells are dying?

C'mon. No fetal heart tones. You put a pulse ox on her, push start on the NIBP, you put your mad spinal skillz aside, and you put her to sleep and secure the airway. First look video laryngoscopy and a tube, if it's not there, you put in an LMA.

 

[fakin' the funk]

I don't think it's insane. During residency I had an attending pop in a spinal in an emergent case in what felt like 30 seconds but was probably under 2 minutes

The point here is we're talking about a real world time not "spinal introducer in the back to spinal dose complete" which for 2 minutes, yeah obviously.

If you're talking baby/mom are in extremis as they roll in the OR door, to when surgeons can cut, IT'S NOT TWO MINUTES, and the hubris to juke the stats like that is just crazy.
Bed rolling in room - table - sitting for spinal - monitors on - dose in and mom laying down is 4-5 minutes at MINIMUM with maximum assistance (say a second anesthesia provider or fully prepped meds/tray).

GA is faster.

 

[GassYous]

The point here is we're talking about a real world time not "spinal introducer in the back to spinal dose complete" which for 2 minutes, yeah obviously.

If you're talking baby/mom are in extremis as they roll in the OR door, to when surgeons can cut, IT'S NOT TWO MINUTES, and the hubris to juke the stats like that is just crazy.
Bed rolling in room - table - sitting for spinal - monitors on - dose in and mom laying down is 4-5 minutes at MINIMUM with maximum assistance (say a second anesthesia provider or fully prepped meds/tray).

GA is faster.

How can it possibly take 5 minutes? Are you waiting for the bp cuff to cycle?

Rush table in, move over, sit up, splash on some chloroprep. 22 whitacre, push in some bupi, lay down

I don't see what you think I will get out of "juking the stats" on a mostly anonymous online forum

 

[Urzuz]

How is there even a discussion going on in this thread? Just ****ing induce GA, intubate/LMA/mask her and tell them to cut.

Some of you people make things so complicated.

 

[staple]

This is a theoretical scenario. Mother is your main patient. Maternal hypoxia from a failed airway, baby dies too

 

[GassYous]

How many times have you had to have emergent GA section in a patient with late decelerations and a known difficult airway? We stock chloroprocaine in our OB drawers. Door in to spinal fully working and cutting can take 4 mins in our place. You don’t think that these late decels have been occurring for the last 20 mins on the floor? An extra 4 minutes for a difficult Airway with baby being monitored is the right thing to do.

I’d like to be a fly on the wall when you explain to the dad why the Mother of his baby is dead after an aspiration or hypoxic event during a failed GA section. Your malpractice will be sending that baby to private college in 18 years

If you take long enough, you probably won't need to pay for college

 

[Southpaw]

I do a lot of OB. No one would ever do a SAB for a true stat CS. Wouldn’t even be up for discussion.

Beyond the time to do the SAB is the time waiting for it to setup.

Yes, the Mom is our primary concern. As listed the airway isn’t that worrisome. Prop, succ, glidescope. Dr. OB please get the baby out.

 

[Urzuz]

This is a theoretical scenario. Mother is your main patient. Maternal hypoxia from a failed airway, baby dies too

Ok, don’t let her get hypoxic.

 

[pgg]

This is a theoretical scenario. Mother is your main patient. Maternal hypoxia from a failed airway, baby dies too

The danger of a pregnant airway is vastly overblown. The OP mentioned the inter-incisor distance is small and the patient is micrognathic but those are cautions not contraindications to an RSI. Neither are likely to make ventilation difficult at all. Neither are likely to make VL fail. Neither are likely to make an LMA fail. And if I saw this airway in preop holding before an elective lap chole, I wouldn't do an awake fiberoptic intubation.

This is a patient who should go to sleep and get a tube.

 

[Hoya11]

You have a patient laboring on the OB floor. She is pre-eclamptic and has multiple signs of difficult airway management. I.e. inter-incisor distance is small, micrognathia etc. You place an epidural for labor analgesia. She ends up needing stat C-section due to fetal bradycardia and decelerations. You end up using the epidural but its miraculously no longer working and there is no time for a spinal. They can't get fetal heart tones.

In this case would you

A. Attempt awake fiberoptic intubation
B. Induce and hope you can intubate
C. Mask down and keep spontaneously breathing in order to get case started and then manage airway with fiberoptic
D. Other alternative?

I was perusing the ASA statement for practice guidelines for OB as well as the difficult airway society OB guideline (UK I believe) and it was unclear to me if you had an emergent OB scenario due to fetal well being but mother was at high risk for failed airway and thus at high risk for morbidity whether you should proceed.

What would you all do?

in the real world - you dont let yourself get into that situation.

when you are doing the epidural for this person, if you think the airway is so terrible that you wouldnt do GA for a stat section (ive never had this thought about anyone), have a conversation then with the OB team. So that if any suspicion of needs a CS, they know your plan A is spinal, so give you some lead time..

 

[Mman]

first question with urgent csection from me is asking OB if I have time to try a spinal. If not, off to sleep.

in the real world - you dont let yourself get into that situation.

when you are doing the epidural for this person, if you think the airway is so terrible that you wouldnt do GA for a stat section (ive never had this thought about anyone), have a conversation then with the OB team. So that if any suspicion of needs a CS, they know your plan A is spinal, so give you some lead time..

here is my real world decision process.

Urgent/stat c-section determination by OB
As we roll in room I ask OB if I have time to try a spinal
If yes...spinal
If no...night night

 

[Arch Guillotti]

first question with urgent csection from me is asking OB if I have time to try a spinal. If not, off to sleep.


here is my real world decision process.

Urgent/stat c-section determination by OB
As we roll in room I ask OB if I have time to try a spinal
If yes...spinal
If no...night night

Exactly.

The only exception is if a can't intubate/can't ventilate scenario is guaranteed, which is a difficult scenario to conjure up.