Another OB case

[Noyac]

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This one is pretty simple but I'm sure there will be a discussion.

In order to keep the pt privacy in tact I have changed some particulars.

30+ yo G >15 P>8 holy roller with all deliveries at home without help. Presents with a cervical mass found to be very vascular on the anterior cervix. Plan is for elective c/s. Pt terribly afraid of needles.

Plan?

 

[Planktonmd]

If a patient is terribly afraid of needles I usually give her some Propofol while the spinal is being done.
Most of the time that's all you need.
If that doesn't work (unlikely) then GA it is.

 

[rsgillmd]

I've never tried Propofol like Plank suggested, although I have given Versed -- usually 1 mg before they go in the OR, and another 1 mg in the OR if needed.

Refusal of neuraxial technique is an absolute contraindication to it. While I'm not afraid to use GA on any patient, I do have respect for its potential harms. Tthey may not get RSI if the plan is GA -- I did an awake fiberoptic on the last eclamptic I intubated -- but they'll get GA. Usually with preparation things go smoothly.

I have a discussion with the patients about risks/benefits of both regional and general, state my preference (usually regional), and document the discussion. By having a discussion you'll have a chance to address pt. concerns. One of the things I'll tell the patients is that the local needle is smaller than the IV they'll have. I also use the dentist analogy -- after the local they'll know we are working back there and feel the pressure, but it shouldn't hurt and if it does hurt on one side they should verbalize that to us. Finally I remind them of the benefits of seeing their baby shortly after delivery.

Vascular mass on the cervix? Sounds fishy. Have they looked to see if it is a vasa previa? Those can bleed quite a bit.

So in summary, assuming no contraindications, a neuraxial technique is feasible.

 

[dhb]

I agree with the previous posts a regional is ok although i wouldn't push for it as the "cervical mass" could be a vasa praevia , placenta previa and with the history of the patient could well be an accreta / percreta if some of her deliveries were C-sections.

I would have some good piv's from the get go and blood products ready.

 

[pgg]

What do the the OBs think of the mass? If after talking to the OBs I thought a bloodbath was possible (well, more possible than usual), I'd be inclined to go GA from the start for the same reasons I prefer GA for known percretas.

 

[Noyac]

What do the the OBs think of the mass? If after talking to the OBs I thought a bloodbath was possible (well, more possible than usual), I'd be inclined to go GA from the start for the same reasons I prefer GA for known percretas.

Exactly! So an US was performed and the placenta is posterior therefore, the mass does not involve the placenta. I spoke with the OB and he wanted cell saver available for the case. I asked for 2 large bore IV's and as you can imagine that didn't go over to well with the pt. The OB nurse called me and said' "do you really need 2 IV's, she's a hard stick and afraid of needles."

So I go over to OB expecting to have to talk this pt down and place the IV's myself. When I get in the room, she has cotton balls all up and down her arms but 2 18g PIV's placed. Our OB nurses are pretty good. I look at this lady and no **** she looks like Pierre Robin.😱 She has never had surgery. I'm thinking, if she is afraid of needles so much, an awake FOI is gonna suck.

So I tell her she is going to get a spinal and it will be much better than the IV sticks, I promise. Hint: never promise ANYTHING.

 

[ssmallz]

Exactly! So an US was performed and the placenta is posterior therefore, the mass does not involve the placenta. I spoke with the OB and he wanted cell saver available for the case. I asked for 2 large bore IV's and as you can imagine that didn't go over to well with the pt. The OB nurse called me and said' "do you really need 2 IV's, she's a hard stick and afraid of needles."

So I go over to OB expecting to have to talk this pt down and place the IV's myself. When I get in the room, she has cotton balls all up and down her arms but 2 18g PIV's placed. Our OB nurses are pretty good. I look at this lady and no **** she looks like Pierre Robin.😱 She has never had surgery. I'm thinking, if she is afraid of needles so much, an awake FOI is gonna suck.

So I tell her she is going to get a spinal and it will be much better than the IV sticks, I promise. Hint: never promise ANYTHING.

I don't know about your OBs but I would insist on a CSE here b/c this could take a while

 

[IlDestriero]

I look at this lady and no **** she looks like Pierre Robin.😱 She has never had surgery. I'm thinking, if she is afraid of needles so much, an awake FOI is gonna suck.

Most of these severely micrognathic folks, PR included can usually be ventilated OK with a small LMA and easily fibered. Obviously not my first choice in a full stomach, but I thought that I would throw that out there for the crowd.

 

[Planktonmd]

I think you can do wonders with Propofol in patients who are nervous and afraid of needles.
A few years ago I wouldn't have said that since we were always taught that we should not sedate pregnant women, but I discovered that if you titrate Propofol wisely you can achieve any level of sedation you want.
You give 10 mg increments and maintain a conversation with the patient, you will know when the right time is when they start becoming pleasant and talkative while they are sitting on the OR table waiting for the spinal to be done.
The dose you give varies but you are not trying to induce GA you are simply trying to achieve anxiolysis and slight euphoria.
In my opinion this is much better than trying to sedate them with Benzo's since it allows you to titrate to the desired level of sedation precisely.
It takes 10-15 minutes but it works.

 

[rsgillmd]

I think you can do wonders with Propofol in patients who are nervous and afraid of needles.
A few years ago I wouldn't have said that since we were always taught that we should not sedate pregnant women, but I discovered that if you titrate Propofol wisely you can achieve any level of sedation you want.
You give 10 mg increments and maintain a conversation with the patient, you will know when the right time is when they start becoming pleasant and talkative while they are sitting on the OR table waiting for the spinal to be done.
The dose you give varies but you are not trying to induce GA you are simply trying to achieve anxiolysis and slight euphoria.
In my opinion this is much better than trying to sedate them with Benzo's since it allows you to titrate to the desired level of sedation precisely.
It takes 10-15 minutes but it works.

It's definitely logical what you are saying. I had never thought of it until you mentioned it. I will definitely keep it in the back of my mind.

 

[proman]

I think you can do wonders with Propofol in patients who are nervous and afraid of needles.
A few years ago I wouldn't have said that since we were always taught that we should not sedate pregnant women, but I discovered that if you titrate Propofol wisely you can achieve any level of sedation you want.
You give 10 mg increments and maintain a conversation with the patient, you will know when the right time is when they start becoming pleasant and talkative while they are sitting on the OR table waiting for the spinal to be done.
The dose you give varies but you are not trying to induce GA you are simply trying to achieve anxiolysis and slight euphoria.
In my opinion this is much better than trying to sedate them with Benzo's since it allows you to titrate to the desired level of sedation precisely.
It takes 10-15 minutes but it works.

I haven't used propofol for OB spinals, but have for other spinals. It makes positioning extremely easy. They seem to slouch forward into a perfect position.

 

[Idiopathic]

ultimately it should boil down to how high the index of suspicion is that this could turn significantly bloody. if thats the case then i go to sleep with whatever modality i prefer, in an urgent rather than emergent setting. otherwise i place cse in the l+d suite, top it up before going back and make sure my level isnt too high

 

[Noyac]

ultimately it should boil down to how high the index of suspicion is that this could turn significantly bloody. if thats the case then i go to sleep with whatever modality i prefer, in an urgent rather than emergent setting. otherwise i place cse in the l+d suite, top it up before going back and make sure my level isnt too high

Well, this is sort of where I was wanting to go with this. THe OB wanted cell saver and was very concerned about the location of the cervical mass. When we put pregnant pts to sleep the surgeon needs to move lickity split. This is the last thing we need in this case.

My concern was of course that if we get into a **** ton of bleeding and I need to put her to sleep in a less than optimal situation. Would the airway become a problem. How would you guys do this if it was an oral board case?

 

[Idiopathic]

if they are legitimately concerned about bleeding then she goes to sleep, i thought vasa previa was more a fetal concern than maternal and by asking for cell saver the doc is clearly concerned about mom, so who knows whats up.

 

[PL32]

Your concerns about GA and the airway in case of emergency intraop are real, and scary. Would it be advisable to keep her topicalized during the section under neuraxial blockade? ...little hits of lidocaine via atomizer, gauze soaked w lidocaine in her mouth like lollipops. If you have her topicalized in the event of emergency you can try LMA/fiberoptic tube placement. You may even prophylactically place an OGT and empty her stomach. Since she's a wimp, just tape her eyes shut during this stuff.

 

[Planktonmd]

Your concerns about GA and the airway in case of emergency intraop are real, and scary. Would it be advisable to keep her topicalized during the section under neuraxial blockade? ...little hits of lidocaine via atomizer, gauze soaked w lidocaine in her mouth like lollipops. If you have her topicalized in the event of emergency you can try LMA/fiberoptic tube placement. You may even prophylactically place an OGT and empty her stomach. Since she's a wimp, just tape her eyes shut during this stuff.

You are kidding aren't you?
So you are going to tape her eyes while she is awake, place a gastric tube "prophylactically" in her mouth and keep her airway "topicalized" throughout the C section just in case you have to intubate her?

 

[Idiopathic]

awesome

 

[PL32]

No, the last line was clearly a joke. The rest of the ideas I proposed are a little preposterous, and I don't see myself doing those things in reality either, but it was worth throwing it out there.

If it was my case, I'd place a spinal, or probably CSE if I suspected a long, complicated case, which I do. I would avoid GA initially. I think even with moderate blood loss, I would still avoid GA. If the airway was scary enough to want to intubate awake, I would have everything in the room available.

 

[IlDestriero]

No, the last line was clearly a joke. The rest of the ideas I proposed are a little preposterous, and I don't see myself doing those things in reality either, but it was worth throwing it out there.

If it was my case, I'd place a spinal, or probably CSE if I suspected a long, complicated case, which I do. I would avoid GA initially. I think even with moderate blood loss, I would still avoid GA. If the airway was scary enough to want to intubate awake, I would have everything in the room available.

Topicalizing a pregnant woman, removing her protective airway reflexes, and lying her down for a c/s is not unconventional thinking, it's NOT thinking. It guarantees aspiration. She won't even know it's coming until she fills her lungs with this AM's breakfast. They reflux 500 times a day, even when upright.
If you have time, a likely difficult airway, significant aspiration risk and an unusual case that could be both long and with significant blood loss, I think an elective awake fiber is the way to go. You could probably place an epidural, but if the blood loss gets severe, you're going to wish you had secured the airway. Of course, a glidescope would probably be able to rescue you.

 

[fentanyl patch]

the patient is afraid of needles....so who cares. all parturients hate the idea until they are explained why neuraxial is safer than GA. although this cervical mass is "highly vascular", has it been biopsied? It could be anything from cervical cancer to endometriosis. shouldn't this mass be ruled out for cancer? since it will likely change intraop management and possibly necesitate gyn/onc involvement.


if some other reason for the cervical mass was determined, i would place 2 IV's, T&C, and perform a straight epidural. i wouldn't do a CSE in a pt with a difficult airway when you know the case may go long. i want to be confident in my working epidural if the patient does indeed look like Mr. Pierra Robin

 

[PL32]

.

 

[Noyac]

Wow PL32, I hope you have a lot of residency left to go.

Listen to the pro's here. IlD will steer you in the right direction.

 

[PL32]

Wow PL32, I hope you have a lot of residency left to go.

Listen to the pro's here. IlD will steer you in the right direction.

Ouch. Yeah I'm here to learn. If it weren't for the feedback I got on that post, I would have gone around topicalizing all my bad airways that go to c/s under regional

 

[TenaciousGirl]

Noy- what ended up happening with this case??

 

[Noyac]

Noy- what ended up happening with this case??

Well I did my usual spinal.

Except that she got a sympathectomy and temp block but not good enough for the surgical block. I think I probably split the dura with the pencan port. I do it about once every year or 2.

I didn't want this guy rushing through the surgery so I sat her up for an epidural which worked great. I had to talk her into it since she was "afraid" of needles. But I have my ways of making them seeing things my way.😉

All in all, the case went very well. The pt didn't bleed too bad. And I didn't have to intubate her which could have been difficult but probably not impossible.

The case was pretty boring all together but I was curious how many people would have intubated her from the start which I think would have been the wrong approach.