Another OB case

[Noyac]

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But this one is a "what would you have done" case.

Called last night for a c/s. Lady is 5'0" 284# G4 P3 with 3 previous c/s's. She is carrying twins and actively contracting every 3 minutes enough to have to "breath" through it. She ate a full meal 5 hrs earlier and has been drinking mostly clears since. She had at least a quart of water within the last 2hrs. She states that she has "thrown up" at every c/s.
Airway exam: small mouth, MP2, FROM, large breast short neck but looks to be intubatable. She has never been intubated.
Spine exam: No landmarks whatsoever
No other pertinent history.

What would you do?
1) Wait till 2hrs post clears or 8hrs post food or 6 hrs post any oral intake?
2) to the OR plan for spinal?
3) To the OR plan for GETA?
4) Something else?

 

[Laurel123]

to the OR now. This is a lady that requires a c/s for delivery and she is in labor, so it becomes emergent. And being a multip she could suddenly dilate anytime. I would take her now while things are still pretty calm and put in either a spinal or epidural and just get it done. To me, she is an aspiration risk no matter what being obese, pregnant and in labor so I would get her delivered before things are too hairy.

 

[rmh149]

Yup. 3 previous sections and contracting = emergency. Take her to the OR now, plan for spinal. With no landmarks I would probably use an epidural needle as an introducer for a 5" 27g W spinal needle. Zofran 8mg, Reglan, pepcid and bicitra prior to OR. On top of ephedrine, probably have some propofol in small doses for nausea during the section. She is probably going to throw up anyway.

 

[VentdependenT]

But this one is a "what would you have done" case.

Called last night for a c/s. Lady is 5'0" 284# G4 P3 with 3 previous c/s's. She is carrying twins and actively contracting every 3 minutes enough to have to "breath" through it. She ate a full meal 5 hrs earlier and has been drinking mostly clears since. She had at least a quart of water within the last 2hrs. She states that she has "thrown up" at every c/s.
Airway exam: small mouth, MP2, FROM, large breast short neck but looks to be intubatable. She has never been intubated.
Spine exam: No landmarks whatsoever
No other pertinent history.

What would you do?
1) Wait till 2hrs post clears or 8hrs post food or 6 hrs post any oral intake?
2) to the OR plan for spinal?
3) To the OR plan for GETA?
4) Something else?

What a friggen disaster.

To OR, CSE. I'd do it now while you still have time to do it in a non-emergent (but certainly urgent) situation. If I wasn't able to get it then you know what? I'd have awake FOI stuff ready. A PRO-SEAL in the room for Back up in case she's so damn juicy that the saliva will obstruct your view (glyco up front, shouldn't pass through placenta blood barrier because of its fancy quaternary structure).

Call me a newb, because thats what I am.

Eh Noy, btw, how did she have her previous C-Sections? Spinal/epidural/"I dunno, my baby daddy wasn't even there."

VBACSx2 doesn't sound like something I'd like to see happen.

 

[Noyac]

Yup. 3 previous sections and contracting = emergency. Take her to the OR now, plan for spinal. With no landmarks I would probably use an epidural needle as an introducer for a 5" 27g W spinal needle. Zofran 8mg, Reglan, pepcid and bicitra prior to OR. On top of ephedrine, probably have some propofol in small doses for nausea during the section. She is probably going to throw up anyway.

YOu really like the zofran don't you? If you give it up front will it prevent the emesis? I understand the others but not the zofran.

By the way, I don't consider this an emergency. It is urgent as Venti said but not an emergency. Some of you may disagree but if you do please explain.

 

[Laurel123]

YOu really like the zofran don't you? If you give it up front will it prevent the emesis? I understand the others but not the zofran.

By the way, I don't consider this an emergency. It is urgent as Venti said but not an emergency. Some of you may disagree but if you do please explain.

Well, I guess I wouldn't equate it with a crash like a prolapsed cord or something of that nature - but it is in that urgent/emergent nature that would cause me not to wait. I would circle 'E' on my charting and would proceed immediately, but in a controlled manner. It is like the difference between an open fracture in a stable patient and a stab would to the chest - both are emergent and I wouldn't wait for NPO status to do the cases.

 

[VentdependenT]

YOu really like the zofran don't you? If you give it up front will it prevent the emesis? I understand the others but not the zofran.

If she's gonna yack she's gonna yack I suppose. I wouldn't push propofol in this situation. I'd just have ye old vomit basin and my suction handy.

 

[Planktonmd]

It's not an emergency but it's urgent.
Go to the OR and try CSE although there is a good chance that you will fail because she is in so much pain and most likely screaming and will not help you at all.
Your plan B is what matters here, and it's a tough choice no matter what you do.
For the Oral boards you might want to say: OK, Awake Fiberoptic and they might let you slide.
In real life:
Here is what usually happens:
Morbidly obese woman, already very upset that you stuck her 5 times and couldn't get the epidural, screaming constantly and about to pop her uterus.
You want her to let you put a scope in her mouth or nose and tickle her airway! She is not going to let you.
You might think that good topical anesthesia and airway blocks are going to help, but aren't you abolishing her airway reflexes that way? What if she vomits after you numb her airway? Which is what is going to happen most likely.
The other option would be RSI and Tube while you have a couple of other airway devices ready to use, maybe a glidescope?
It's a scary choice but it might be the best choice.
There is really no right answer here.

 

[VentdependenT]

Excellent points plank.

If she's not willing to undergo an awake FOI (yeah you blow her reflexes but now youre trying to secrue an airway....same deal if you put her to sleep) then you gotta go RSI with pent and sux. Grab a 6.0 and 6.5 tube, have a bougie, and a PROSEAL available in case you can see squat.

 

[Planktonmd]

Excellent points plank.

If she's not willing to undergo an awake FOI (yeah you blow her reflexes but now youre trying to secrue an airway....same deal if you put her to sleep) then you gotta go RSI with pent and sux. Grab a 6.0 and 6.5 tube, have a bougie, and a PROSEAL available in case you can see squat.

Is there a reason why you want to use Thiopental versus Propofol??

 

[VentdependenT]

Is there a reason why you want to use Thiopental versus Propofol??

Because thats what all the books say. Supposedly SPT's first pass through the fetal liver means less amount in their blood and thus CNS. I think propofol would be fine as well.

 

[rmh149]

By the way, I don't consider this an emergency. It is urgent as Venti said but not an emergency. Some of you may disagree but if you do please explain.

How is urgent different than emergency in this case?

 

[GeddyLee]

Just do it under local and if she complains tell her she should expect the worse since she's so obese...just kidding!

Man I hate OB!

 

[Disse]

How is urgent different than emergency in this case?

Urgent = will go sometime sooner rather than later but you still have time to think/plan things out

Emergent = you go now and you'd better know what you're doing

Emergent & Urgent are not the same. That you don't know the terminology makes me cringe almost as much as your posts regarding MH.

Being able to distinguish between urgent & emergent cases is basically one of the most important things you should be able to do if you want to practice independently.

I have no idea why I'm responding to this... I don't even like to read this forum any more because of the militants.

 

[rmh149]

Urgent = will go sometime sooner rather than later but you still have time to think/plan things out

Emergent = you go now and you'd better know what you're doing

Emergent & Urgent are not the same.

Being able to distinguish between urgent & emergent cases is basically one of the most important things you should be able to do if you want to practice independently.

I know what it is. I was asking Noyac what his definition of urgent and emergency is. Some have different opinions. If he thinks the patient is urgent and I think the patient is an emergency. Why? Thats why I was asking HIM how HE defines urgent/emergency.

In my opinion, if I am going to ignore the patients NPO status, then I am going to classify the case as an emergency. PERIOD. There is no middle ground. How quickly we need to move to the OR? Then according to your definition of urgent, I agree, it is urgent, not an emergency (crash c-section). But I am still going to document it as an emergency.

In the end, I probably call my emergency the same as his urgent. I prefer to go with Crash C-section, and emergency C-section. But on paper, they both go down as emergencies.

 

[Noyac]

I know what it is. I was asking Noyac what his definition of urgent and emergency is. Some have different opinions. If he thinks the patient is urgent and I think the patient is an emergency. Why? Thats why I was asking HIM how HE defines urgent/emergency.

In my opinion, if I am going to ignore the patients NPO status, then I am going to classify the case as an emergency. PERIOD. There is no middle ground. How quickly we need to move to the OR? Then according to your definition of urgent, I agree, it is urgent, not an emergency (crash c-section). But I am still going to document it as an emergency.

In the end, I probably call my emergency the same as his urgent. I prefer to go with Crash C-section, and emergency C-section. But on paper, they both go down as emergencies.

My definition is the same as Disse as should yours be.

If you put down emergency for this then it is fraud. You are over billing the pt or their insurance.

Once again, clueless.

 

[rmh149]

My definition is the same as Disse as should yours be.

If you put down emergency for this then it is fraud. You are over billing the pt or their insurance.

Once again, clueless.

No reason to be offensive.

According to the ASA Classification, an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.

Do you disagree?

If not, which I dont think you do, then calling this c-section an emergency on a full stomach, previous c-section (3 times) parturient that is contracting every three minutes is NOT WRONG and NOT FRAUD. Because I am not going to delay the case due to her NPO status it is an emergency. Because she is a full stomach, the risk of anesthesia increases. With this increased risk, she gets an "E" next to her ASA classification.

 

[Noyac]

No reason to be offensive.

According to the ASA Classification, an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.

Do you disagree?

If not, which I dont think you do, then calling this c-section an emergency on a full stomach, previous c-section (3 times) parturient that is contracting every three minutes is NOT WRONG and NOT FRAUD. Because I am not going to delay the case due to her NPO status it is an emergency. Because she is a full stomach, the risk of anesthesia increases. With this increased risk, she gets an "E" next to her ASA classification.

WRONG!

Emergency is if her uterus bursts.

Urgent is what we are dealing with right now. Sure it can become emergent but it is not emergent at this point.

It is my understanding that If you get audited and they see that the surgeon did not declare the case an emergency which they would not have for this scenario then you can be fined, large. You can't call something emergent just b/c it stresses you out.

And if I come off offensive it is only b/c you refuse to learn anything here. You argue your point endlessly to no avail. You beat around the bush and play games with words. You twist everything we say.

 

[Noyac]

In my opinion, if I am going to ignore the patients NPO status, then I am going to classify the case as an emergency. PERIOD. There is no middle ground.

There is middle ground and if you document it, it will be understood.

Example: You write that the pts NPO status warrants an 8hr wait however her medical status will put her in undue risk if the case is delayed 8hrs. Uterine rupture is a great risk here and it is agreed by all involved that we proceed with cesarean at this time.

 

[rmh149]

WRONG!

Emergency is if her uterus bursts.

Urgent is what we are dealing with right now. Sure it can become emergent but it is not emergent at this point.

It is my understanding that If you get audited and they see that the surgeon did not declare the case an emergency which they would not have for this scenario then you can be fined, large. You can't call something emergent just b/c it stresses you out.

You are correct. The surgeon and I have to be on the same page....and they are.

The surgeons I work for understand if I am going to do an anesthetic on a patient with a full stomach, they are emergent and the surgeon declares it an emergency as well. Otherwise, they wait the 6 hours recommended. Of course some emergencies are more emergent than others. I just dont mess around with calling it urgent or emergent. It is either an emergency or not. I keep it simple.

Where did I say that I call it emergency when I get "stressed"? Nope, never. Or are you just being rude because I am a CRNA? Dont have to answer that...I already know.

I understand your middle ground documentation as far as proceeding despite NPO status. I just dont think it is necessary in my situation at our facility if both the surgeon and I are on the same page on paper as far as declaring it an emergency or not.

If I go somewhere else I may very well do what you do if the communication between the surgeons and the anesthetists were not very strong.

 

[Planktonmd]

You are correct. The surgeon and I have to be on the same page....and they are.

The surgeons I work for understand if I am going to do an anesthetic on a patient with a full stomach, they are emergent and the surgeon declares it an emergency as well. Otherwise, they wait the 6 hours recommended. Of course some emergencies are more emergent than others. I just dont mess around with calling it urgent or emergent. It is either an emergency or not. I keep it simple.

Where did I say that I call it emergency when I get "stressed"? Nope, never. Or are you just being rude because I am a CRNA? Dont have to answer that...I already know.

I understand you middle ground documentation as far as proceeding despite NPO status. I just dont think it is necessary in my situation at our facility if both the surgeon and I are on the same page on paper as far as declaring it an emergency or not.

If I go somewhere else I may very well do what you do if the communication between the surgeons and the anesthetists were not very strong.

I think you know very well by now that you are not being mistreated because you are a CRNA. You are usually criticized because you make statements that reflect your lack of knowledge and common sense and even if we take the time to try to teach you something your main focus would be on trying to prove your point even if it didn't make sense.
For example, this thread was about managing an OB case that presents important teaching points and could trigger meaningful exchange of ideas, you are trying hard to turn it in to a stupid game of words, don't you agree that this is not very helpful?
If you want to keep bringing up the fact that you are an independent CRNA and claim that you have a certain level of knowledge, people will expect you to reflect that knowledge in your arguments otherwise they will not take you seriously.

 

[chimichanga]

...For example, this thread was about managing an OB case that presents important teaching points and could trigger meaningful exchange of ideas, you are trying hard to turn it in to a stupid game of words...

I have no stake in either side, just passing through...

But he answered the scenario, and "everyone else turned it in to a stupid game of words" and piled on...

He may be contrary and argumentative daily, in every other thread, but here, he simply answered the question...

...I don't even like to read this forum any more because of the militants.

rmh wasn't the militant one this time...

 

[Planktonmd]

I have no stake in either side, just passing through...

But he answered the scenario, and "everyone else turned it in to a stupid game of words" and piled on...

He may be contrary and argumentative daily, in every other thread, but here, he simply answered the question...

No he did not!
He was trying to tell us the difference between urgent and emergent in his personal view and at his specific location!
That has nothing to do with the subject of this thread.
By the way defending another person just because he is a nurse is in my opinion a militant act.

 

[jwk]

No reason to be offensive.

According to the ASA Classification, an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.

Do you disagree?

If not, which I dont think you do, then calling this c-section an emergency on a full stomach, previous c-section (3 times) parturient that is contracting every three minutes is NOT WRONG and NOT FRAUD. Because I am not going to delay the case due to her NPO status it is an emergency. Because she is a full stomach, the risk of anesthesia increases. With this increased risk, she gets an "E" next to her ASA classification.

She'd get an E from me as well - if you're a walk-in unannounced patient with a previous C/S and in labor, you're gonna get cut sooner rather than later.

That being said, there is definitely a difference between urgent and emergent from a standpoint of getting it done quickly. An emergent case bumps everyone - prolapsed cord, heart tones in the 40's, etc. A repeat C/S in labor, or a failure to progress are not emergent - they can get in line with the other repeat C/S in labor or failure to progress case. If we have four OB OR's running, we're keeping our 5th one available for the emergent case - we won't use it for the urgent one.

I reviewed a case a couple years ago that keyed on this very subject. Small hospital, the pt was failure to progress, the OB offered her the option of a C/S or laboring another hour or two (after 24 hrs). Pt wanted a C/S - the anesthesiologist was called in from home, and the C/S started less than 45 minutes from the time the anesthesiologist was called. Bad baby. The OB later claimed the C/S was an emergency and should have started within 30 minutes. However, the hospital had a very detailed "emergency C-Section" policy that included the house supervisor running and opening the OR and helping set up the case for the C/S team and specified a very exact list/timeline of procedures to follow, starting with the OB declaring it an "emergency". He did not. The hospital and OB reached a significant dollar settlement - the anesthesiologist paid $0 .

Urgent and emergent are not the same thing, but urgent can most certainly be considered an "emergency" as far as ASA classification and billing purposes.

 

[jetproppilot]

But this one is a "what would you have done" case.

Called last night for a c/s. Lady is 5'0" 284# G4 P3 with 3 previous c/s's. She is carrying twins and actively contracting every 3 minutes enough to have to "breath" through it. She ate a full meal 5 hrs earlier and has been drinking mostly clears since. She had at least a quart of water within the last 2hrs. She states that she has "thrown up" at every c/s.
Airway exam: small mouth, MP2, FROM, large breast short neck but looks to be intubatable. She has never been intubated.
Spine exam: No landmarks whatsoever
No other pertinent history.

What would you do?
1) Wait till 2hrs post clears or 8hrs post food or 6 hrs post any oral intake?
2) to the OR plan for spinal?
3) To the OR plan for GETA?
4) Something else?

This lady's body dimensions are very common in Louisiana....as I'm sure Noy can recall.

Last time I was OB doc I did 2 C sections on ladies over 300 lbs. People really love the fried seafood around here.

Spinal with a 22" SN. Aint gonna get there with the 25".

Have yet to see a morbidly obese woman get a spinal headache.

Backup plan would be CSE. Sometimes I can find the space easier with the Tuohy than the SN. Dont really know why.

 

[Noyac]

This lady's body dimensions are very common in Louisiana....as I'm sure Noy can recall.

Last time I was OB doc I did 2 C sections on ladies over 300 lbs. People really love the fried seafood around here.

Spinal with a 22" SN. Aint gonna get there with the 25".

Have yet to see a morbidly obese woman get a spinal headache.

Backup plan would be CSE. Sometimes I can find the space easier with the Tuohy than the SN. Dont really know why.

Jet I feel like I'm back in La. This pt was Friday night. I came back on call Sunday morning and the very first case I did was a 320# c/s. Good thing I did these routinely in La. 😀

 

[Noyac]

The OB later claimed the C/S was an emergency and should have started within 30 minutes.

Urgent and emergent are not the same thing, but urgent can most certainly be considered an "emergency" as far as ASA classification and billing purposes.

I'm not so sure of that, JWK.

And you answered my next comment is that emergent c/s's need to be done in 20-30 minutes from decision to incision. Depending on your hospitals policy. So this case would not meet that criteria. Therefore, urgent and not emergent. But you guys can continue to put E for these cases even though the OB provider doesn't and hope not to get audited.

We were told in my last group and present group by our billing company that we needed to get the surgeon to write emergency for any case that went to the OR that we declared emergency or we could not bill for it as an "E". In the same sentence we were told that if we billed an E for a case that is not a true emergency and get audited we would face serious fines.

 

[TIVA]

Wow ... looking back I must have overbilled almost every pregnant lady during residency since I was taught that an epidural for labor is an "emergency." After all, when the patient wants an epidural, you don't wait till the following morning, nor wait for NPO clearance, you go immediately and put it in. As such, every labor epidural got marked "ASA II-IV / E".

 

[jetproppilot]

Wow ... looking back I must have overbilled almost every pregnant lady during residency since I was taught that an epidural for labor is an "emergency." After all, when the patient wants an epidural, you don't wait till the following morning, nor wait for NPO clearance, you go immediately and put it in. As such, every labor epidural got marked "ASA II-IV / E".

Calling a labor epidural an emergency is stretching it, dontcha think?

 

[Noyac]

Wow ... looking back I must have overbilled almost every pregnant lady during residency since I was taught that an epidural for labor is an "emergency." After all, when the patient wants an epidural, you don't wait till the following morning, nor wait for NPO clearance, you go immediately and put it in. As such, every labor epidural got marked "ASA II-IV / E".

Yeah I remember those days.

 

[epidural man]

Spinal with a 22" SN. Aint gonna get there with the 25".

Have yet to see a morbidly obese woman get a spinal headache.

Sometimes I can find the space easier with the Tuohy than the SN.

Tuoy is your best spinal needle! If I couldn't find the space with a 22gauge quincke, I would use a touy and thread an intrathecal catheter. Maybe an intrathecal catheter should be your first choice - you know it will work, and the surgeons can have all day to get this the baby out on this fat lady with -no doubt - tons of adhesions. In our hospital, this surgery is going to take at least 1.5 hrs. If you do a single shot spinal, you will be supplementing with ketamine or nitrous by the end.

 

[Noyac]

Tuoy is your best spinal needle! If I couldn't find the space with a 22gauge quincke, I would use a touy and thread an intrathecal catheter. Maybe an intrathecal catheter should be your first choice - you know it will work, and the surgeons can have all day to get this the baby out on this fat lady with -no doubt - tons of adhesions. In our hospital, this surgery is going to take at least 1.5 hrs. If you do a single shot spinal, you will be supplementing with ketamine or nitrous by the end.

A touhy is an good option but I used a 22g Pencan single shot with 13mg bupiv and 250mcg PFMS. Case lasted 1.5hrs due to many adhesions and I never had to supplement the block with ketamine or anything for that matter.

 

[Noyac]

Jet I feel like I'm back in La. This pt was Friday night. I came back on call Sunday morning and the very first case I did was a 320# c/s. Good thing I did these routinely in La. 😀

Oh **** I'm having a bad flashback of La. 4am this morning I get called for another c/s. Breech 9cm bulging bag contracting every 2-3min. Guess what? She's the biggest yet. 300+ lbs and just ate. She ate at 4am😱

22g Pencan again.

The combined weight of my 3 c/s this weekend was over 900lbs.

 

[Laurel123]

Oh **** I'm having a bad flashback of La. 4am this morning I get called for another c/s. Breech 9cm bulging bag contracting every 2-3min. Guess what? She's the biggest yet. 300+ lbs and just ate. She ate at 4am😱

22g Pencan again.

The combined weight of my 3 c/s this weekend was over 900lbs.

Yikes! But that's the way it is, the big gals are never NPO.

 

[Trisomy13]

I just dont mess around with calling it urgent or emergent. It is either an emergency or not. I keep it simple.

Yes. Yes you do.

 

[Trisomy13]

This lady's body dimensions are very common in Louisiana....as I'm sure Noy can recall.

Last time I was OB doc I did 2 C sections on ladies over 300 lbs. People really love the fried seafood around here.
.

around here that is referred to as "three West Virginia units".

we invented fat people.

 

[jetproppilot]

Tuoy is your best spinal needle! If I couldn't find the space with a 22gauge quincke, I would use a touy and thread an intrathecal catheter. Maybe an intrathecal catheter should be your first choice - you know it will work, and the surgeons can have all day to get this the baby out on this fat lady with -no doubt - tons of adhesions. In our hospital, this surgery is going to take at least 1.5 hrs. If you do a single shot spinal, you will be supplementing with ketamine or nitrous by the end.

Yeah, thats a good point. Gives me the heebie-jeebies though to breach the dura with a sword. 😱

 

[jetproppilot]

Oh **** I'm having a bad flashback of La. 4am this morning I get called for another c/s. Breech 9cm bulging bag contracting every 2-3min. Guess what? She's the biggest yet. 300+ lbs and just ate. She ate at 4am😱

22g Pencan again.

The combined weight of my 3 c/s this weekend was over 900lbs.

HAHAHAHAHAHAHAHAHAHAHAHAHAHA

You're a regular FREE WILLY anesthesiologist, Mikey!

Keep it up and they're gonna hafta build a new OR bed for you that will accomodate blow-holes.

 

[proclivity]

HAHAHAHAHAHAHAHAHAHAHAHAHAHA

You're a regular FREE WILLY anesthesiologist, Mikey!

Keep it up and they're gonna hafta build a new OR bed for you that will accomodate blow-holes.

LMAO!!!......that is so wrong.

 

[rmh149]

Yes. Yes you do.

Because it IS simple. Do you want to elaborate? Or were you just trying to be insulting?

 

[Trisomy13]

Because it IS simple. Do you want to elaborate? Or were you just trying to be insulting?

Anything is simple if you ignore nuance. My comment was on your ignoring the difference between urgent and emergent, then later saying something to the effect of "some emergencies are more emergent than others", but you would rather just call anything emergency and be done with it.

 

[rmh149]

Anything is simple if you ignore nuance. My comment was on your ignoring the difference between urgent and emergent, then later saying something to the effect of "some emergencies are more emergent than others", but you would rather just call anything emergency and be done with it.

I dont ignore the difference between urgen and emergent.

In reference to the ASA status and what I document on the chart....yes, it is either emergent or not emergent.

At our facility, if the case is not going to be delayed because of NPO status, it is classified as an emergency. Of course a ruptured uterus or prolapsed cord is going to be higher on the list than a contracting previous section. We just dont dwell on the terminology of which one is emergent, urgent, semi-emergent, etc. But they are all emergencies if you are going to not delay the case.

An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.